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Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study
Duminda N Wijeysundera1, Harindra C Wijeysundera, Lingsong Yun
1Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. d.wijeysundera@utoronto.ca
Insights
Elective surgery should be delayed 46-180 days after bare-metal stent implantation and over 180 days after drug-eluting stent implantation to minimize cardiac events.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Health Services Research
Background:
- Current guidelines recommend delaying noncardiac surgery until 30-45 days post-bare-metal stent (BMS) and 1 year post-drug-eluting stent (DES).
- Optimal timing for noncardiac surgery after coronary stent implantation remains a critical clinical question.
Purpose of the Study:
- To determine the optimal timing for major elective noncardiac surgery after coronary stent implantation.
- To evaluate the association between the timing of surgery and major adverse cardiac events (MACE).
Main Methods:
- A cohort study of 8116 patients (≥40 years) undergoing major elective noncardiac surgery in Ontario, Canada (2003-2009) after coronary stent implantation.
- Linked registry and administrative health care data were used to track 30-day MACE (mortality, acute coronary syndrome, repeat revascularization).
- A comparison cohort of 341,350 surgical patients without prior coronary revascularization was included.
Main Results:
- The overall 30-day MACE rate in patients with coronary stents was 2.1%.
- Event rates were highest when surgery occurred <45 days post-stent (BMS: 6.7%, DES: 20.0%).
- For BMS, event rates decreased to 2.6% at 45-180 days and approached nonrevascularized individuals' rates after 180 days.
- For DES, event rates were 1.2% after 180 days, similar to the nonrevascularized group.
Conclusions:
- The earliest optimal interval for elective surgery is 46 to 180 days after BMS implantation.
- For DES, surgery should be delayed for more than 180 days to achieve similar safety profiles.
- These findings refine current recommendations for perioperative management of patients with coronary stents.
Background:
Guidelines recommend that noncardiac surgery be delayed until 30 to 45 days after bare-metal stent implantation and 1 year after drug-eluting stent implantation.
Methods And Results:
We used linked registry data and population-based administrative health care databases to conduct a cohort study of 8116 patients (≥40 years of age) who underwent major elective noncardiac surgery in Ontario, Canada between 2003 and 2009, and received coronary stents within 10 years before surgery. Approximately 34% (n=2725) underwent stent insertion within 2 years before surgery, of whom 905 (33%) received drug-eluting stents. For comparison, we assembled a separate cohort of 341 350 surgical patients who had not undergone coronary revascularization. The primary outcome was 30-day major adverse cardiac events (mortality, readmission for acute coronary syndrome, or repeat coronary revascularization). The overall rate of 30-day events in patients with coronary stents was 2.1% (n=170). When the interval between stent insertion and surgery was <45 days, event rates were high for bare-metal (6.7%) and drug-eluting (20.0%) stents. When the interval was 45 to 180 days, the event rate for bare-metal stents was 2.6%, approaching that of intermediate-risk nonrevascularized individuals. Adjusted analyses suggested that event rates were increased if this interval exceeded 180 days. For drug-eluting stents, the event rate was 1.2% once the interval exceeded 180 days, approaching that of intermediate-risk nonrevascularized individuals.
Conclusions:
The earliest optimal time for elective surgery is 46 to 180 days after bare-metal stent implantation or >180 days after drug-eluting stent implantation.
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