Noncardiac surgery after percutaneous coronary intervention
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
- Steven L Cohn, MD, FACP, SFHM
Steven L Cohn, MD, FACP, SFHM
- Professor of Clinical Medicine
- University of Miami Miller School of Medicine
- Section Editors
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
The management of antiplatelet therapy in patients who need noncardiac surgery after percutaneous coronary intervention (PCI) with stenting requires consideration of the competing risks of acute coronary events with premature cessation and bleeding with continuation of antiplatelet therapy. This is an important clinical problem, as it is estimated that about 5 to 10 percent of patients with coronary stents undergo noncardiac surgery within one year of stent implantation [1-5].
This topic will focus on the approach to patients scheduled to undergo elective noncardiac surgery after PCI with stenting and who are taking dual antiplatelet therapy. Patients who require urgent or emergent surgery or those who receive balloon angioplasty are also discussed briefly. The approach to antiplatelet therapy in patients scheduled for coronary artery bypass graft surgery is presented separately. (See "Medical therapy to prevent complications after coronary artery bypass graft surgery", section on 'Preoperative aspirin' and "Medical therapy to prevent complications after coronary artery bypass graft surgery", section on 'Platelet P2Y12 receptor blocker therapy'.)
The larger discussion of the risk of coronary artery stent thrombosis, one of the potential complications of discontinuing antiplatelet therapy prior to noncardiac surgery, is found elsewhere. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients" and "Coronary artery stent thrombosis: Incidence and risk factors".)
For this topic, major surgery is defined as any surgery for which the surgeon might recommend the discontinuation of dual antiplatelet therapy due to a concern for an increase in bleeding risk. Most studies that have evaluated this issue have included patients scheduled to undergo peripheral arterial, orthopedic, abdominal, or thoracic surgery, or radical prostatectomy, nephrectomy, or cystectomy.
Dual antiplatelet therapy refers to the combination of aspirin plus a P2Y12 receptor blocker such as clopidogrel, prasugrel, or ticagrelor.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Cruden NL, Harding SA, Flapan AD, et al. Previous coronary stent implantation and cardiac events in patients undergoing noncardiac surgery. Circ Cardiovasc Interv 2010; 3:236.
- Berger PB, Kleiman NS, Pencina MJ, et al. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv 2010; 3:920.
- Gandhi NK, Abdel-Karim AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv 2011; 77:972.
- Hawn MT, Graham LA, Richman JR, et al. The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg 2012; 214:658.
- Hawn MT, Graham LA, Richman JS, et al. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA 2013; 310:1462.
- Kałuza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000; 35:1288.
- Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003; 42:234.
- Reddy PR, Vaitkus PT. Risks of noncardiac surgery after coronary stenting. Am J Cardiol 2005; 95:755.
- Holmes DR Jr, Kereiakes DJ, Garg S, et al. Stent thrombosis. J Am Coll Cardiol 2010; 56:1357.
- Diamantis T, Tsiminikakis N, Skordylaki A, et al. Alterations of hemostasis after laparoscopic and open surgery. Hematology 2007; 12:561.
- Rajagopalan S, Ford I, Bachoo P, et al. Platelet activation, myocardial ischemic events and postoperative non-response to aspirin in patients undergoing major vascular surgery. J Thromb Haemost 2007; 5:2028.
- Li N, Astudillo R, Ivert T, Hjemdahl P. Biphasic pro-thrombotic and inflammatory responses after coronary artery bypass surgery. J Thromb Haemost 2003; 1:470.
- Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation 2005; 111:3481.
- Mahla E, Lang T, Vicenzi MN, et al. Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth Analg 2001; 92:572.
- Samama CM, Thiry D, Elalamy I, et al. Perioperative activation of hemostasis in vascular surgery patients. Anesthesiology 2001; 94:74.
- Beving H, Zhao C, Albåge A, Ivert T. Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment. Blood Coagul Fibrinolysis 1996; 7:80.
- Schouten O, van Domburg RT, Bax JJ, et al. Noncardiac surgery after coronary stenting: early surgery and interruption of antiplatelet therapy are associated with an increase in major adverse cardiac events. J Am Coll Cardiol 2007; 49:122.
- Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.
- Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation 2012; 126:1355.
- Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2016; 67:1038.
- Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol 2014; 64:2730.
- Brilakis ES, Dangas GD. What to do when a patient with coronary stents needs surgery? J Am Coll Cardiol 2014; 64:2740.
- Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005; 45:456.
- Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 2006; 27:2667.
- Rossini R, Musumeci G, Capodanno D, et al. Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery. Results of a multicentre registry. Thromb Haemost 2015; 113:272.
- Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007; 99:316.
- Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257:399.
- Singla S, Sachdeva R, Uretsky BF. The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention. J Am Coll Cardiol 2012; 60:2005.
- Dweck MR, Cruden NL. Noncardiac surgery in patients with coronary artery stents. Arch Intern Med 2012; 172:1054.
- Brilakis ES, Banerjee S, Berger PB. Perioperative management of patients with coronary stents. J Am Coll Cardiol 2007; 49:2145.
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
- Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S.
- Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1082.
- Savonitto S, D'Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of 'bridging' antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth 2010; 104:285.
- Rassi AN, Blackstone E, Militello MA, et al. Safety of "bridging" with eptifibatide for patients with coronary stents before cardiac and non-cardiac surgery. Am J Cardiol 2012; 110:485.
- Huang PH, Croce KJ, Bhatt DL, Resnic FS. Recommendations for management of antiplatelet therapy in patients undergoing elective noncardiac surgery after coronary stent implantation. Crit Pathw Cardiol 2012; 11:177.
- - Premature cessation of antiplatelet therapy
- - Prothrombotic and proinflammatory effects of surgery
- - Incomplete strut coverage
- Timing, incidence, and clinical predictors
- OUR APPROACH
- Elective noncardiac surgery in stented patients
- Urgent or emergent noncardiac surgery
- Patients with prior balloon angioplasty
- RECOMMENDATIONS OF OTHERS
- POTENTIAL ALTERNATIVES TO DUAL ANTIPLATELET THERAPY
- SUMMARY AND RECOMMENDATIONS