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.
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- - 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