Non-Cardiac Surgery in Patients With Coronary Stents: The RECO Study

Study Questions:

What is the rate of major adverse cardiac and cerebrovascular events (MACCE) and major or minor bleeding complications and their associated independent correlates in coronary stented patients undergoing urgent or planned noncardiac surgery?

Methods:

This was a prospective, multicenter, observational cohort study of 1,134 consecutive patients with coronary stents. Participating centers prospectively enrolled consecutive patients with coronary stents who underwent elective or urgent noncardiac surgery or another invasive procedure. Invasive procedure was defined as all noncardiac surgeries including diagnostic endoscopy and all procedures requiring anesthesia. The coprimary endpoints consisted of the incidence of MACCE and major bleeding within the first 30 days of an invasive procedure.

Results:

MACCE and hemorrhagic complications were observed in 124 (10.9%) and 108 (9.5%) patients, respectively, within an average time delay from invasive procedure to event of 3.3 ± 3.9 and 5.3 ± 5.3 days. Independent preoperative correlates for MACCE were complete oral antiplatelet therapy (OAT) interruption for more than 5 days prior to surgery, preoperative hemoglobin <10 g/dl, creatinine clearance of <30 ml/min, and emergency or high-risk surgery. Independent factors for hemorrhagic complications were preoperative hemoglobin <10 g/dl, creatinine clearance between 30 and 60 ml/min, a delay from stent implantation to surgery <3 months, and high-risk surgery according to the Lee classification.

Conclusions:

The authors concluded that patients with coronary stents undergoing an invasive procedure are at high risk of perioperative myocardial infarction including stent thrombosis irrespective of the stent type.

Perspective:

This prospective observational study found that postoperative MACCE occurred in 10.9% of patients with coronary stents who underwent noncardiac surgery or other invasive procedure, and bleeding events occurred in 9.5%. The type of stent was not identified as a risk factor. Overall, patients with coronary stents undergoing noncardiac surgery are exposed to a high risk of cardiovascular and hemorrhagic complications. Maintaining OAT throughout surgical and invasive procedures is the key to avoiding cardiovascular complications without increasing hemorrhagic risk. If interrupting OAT treatment is absolutely essential (which should be rare), a delay between interruption and surgery of <5 days is recommended for patients treated with aspirin, clopidogrel, or both.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Aortic Surgery, Cardiac Surgery and SIHD, Chronic Angina

Keywords: Myocardial Infarction, Coronary Restenosis, Ticlopidine, Endoscopy, Risk Factors, Creatinine, Angioplasty, Stents, Hemoglobins, Thrombosis, Cardiology, Cardiac Surgical Procedures, Hemorrhage


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