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Coronary stents and risk of major adverse cardiac events following noncardiac surgery: the change

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When I was working in my thesis a few years ago, I began to learn how to discriminate some scientific articles about their  relevance in certain issues, which kept as «classics». Later, in my clinical practice, I used to save as a treasure some articles (eg Amato and lung protective ventilation).

 

Now, the original published in October 2013 in JAMA aims, in my opinion, to become a turning point in the management of patients with coronary stents following  noncardiac surgery. The published study conducted by Hawn and cols., Department of Surgery, University of Alabama, takes a retrospective cohort study of patients undergoing noncardiac surgery within two years following the placement of a coronary stent to examine the relationship of the type of stent and the time between percutaneous coronary intervention and non cardiac surgery with major adverse cardiac events.

 

The current recommendation for patients with drug eluting stents (Class IIa, level of evidence C) is that elective surgery after drug eluting stent implantation should be delayed until completion of one year of dual antiplatelet therapy, and, in case of urgent surgery, it should be performed without interruption of antiplatelet therapy. In case of bare metal  stents, the surgery is delayed 4 to 6 weeks. Hawn and cols. encourages for this reason about level of evidence C to study better the relationship between the type of stent, antiplatelet therapy and related major adverse cardiac events following noncardiac surgery after coronary stent implantation.

 

They performed three analysis:

First, multivariable regression to determine risk factors for major adverse cardiac events. Second study whether major adverse cardiac event rate is a function of time from stent implantation and surgery, and the type of stent. Lastly 3rd analyzed the association of the cessation of antiplatelet therapy and major adverse cardiac events.

Between 2000 and 2010 there were 124,844 percutaneous coronary interventions, of which 22.5% met the inclusion criteria, 28,029 patients with 41,989 surgeries within two years after stent implantation. In the first month after surgery,  4.7% of major adverse cardiac events (1980 cases) were detected.

 

Nonelective presentation for the surgical hospitalization was the most explanatory determinant factor for the occurrence of major adverse cardiac events after noncardiac surgery in these patients, followed by conditions like recent myocardial infarction, congestive heart failure or higher revised cardiac risk index score. However, the type of stent and the set time delay for surgery were not associated with an increased incidence of adverse outcomes. Furthermore, there was no association between discontinuation of antiplatelet therapy and the occurrence of major adverse cardiac events.

 

Moreover, patients taken dual antiplatelet therapy had the highest rates of adverse cardiac events, not only because these patients were precisely those with the highest cardiac risk, but also because perioperative bleeding itself was the leading cause of the highest rate of adverse outcomes.

 

If this is the starting point for a reassessment of the clinical practice guidelines, only time will tell us.

 

 

 

 

 

 

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