We read with interest the article from Hawn et al entitled “Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents” . The authors make a retrospective cohort study with patients undergoing noncardiac surgery within 2 years of coronary stent placement to examine the relationship of the type of stent, antiplatelet therapy and the time between percutaneous coronary intervention and noncardiac surgery with major adverse cardiac events.
In their analysis, 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.
However, we would like to do some clinical considerations about high risk bleeding surgery. Nowadays there is a clinical dilemma about antiplatelet therapy and intracranial surgery. We think that there is an important conclusion in this study because its possible application to intracranial neurosurgery. The publication of the 2007 ACC/AHA guidelines recommend that aspirin should only be discontinued if the known bleeding risks are similar or more severe than the observed cardiovascular risks of aspirin withdrawal, with possible exceptions: intracranial surgery and prostatectomy, similarly to the 2012 update to the Society of the Thoracic Surgeons Guideline. Recently, the STRATAGEN trial did not identify a difference in the incidence of mayor thrombotic events between a strategy of interruption of antiplatelets before elective noncardiac surgery and a strategy of preoperative maintenance of aspirin in stable patients chronically treated with antiplatelet therapy for secondary prevention. Moreover, Hawn et al show that patients with coronary stents 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 as the leading cause of the highest rate of adverse outcomes.
This supports the strategy to discontinue antiplatelet therapy, like a recommendation better than a possible exception, for both primary and secondary prevention, and also for patients with coronary stents before intracraneal surgery.
1. Hawn MT, Graham LA, Richman JS, Itani KMF, Henderson WG, Maddox TM. Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents. JAMA. 2013 Oct 9;310(14):1462–72.
2. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007 Oct 8;116(17):e418–e500.
3. Ferraris VA, Saha SP, Oestreich JH, Song HK, Rosengart T, Reece TB, et al. 2012 Update to The Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and Noncardiac Operations*. ATS. Elsevier Inc; 2012 Nov 1;94(5):1761–81.
4. Mantz J, Samama CM, Tubach F, Devereaux PJ, Collet JP, Albaladejo P, et al. Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial. British Journal of Anaesthesia. 2011 Nov 16;107(6):899–910.