Risk of Elective Major Noncardiac Surgery After Coronary Stent Insertion: A Population-Based Study

Study Questions:

What are the outcomes of patients who undergo elective intermediate- to high-risk noncardiac surgery after stent implantation?

Methods:

The investigators used linked registry data and population-based administrative health care databases to conduct a cohort study of 8,116 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. The primary outcome was a major adverse cardiac event (MACE), defined as mortality, readmission for acute coronary syndrome (ACS), or coronary revascularization, within 30 days after the index surgery. The secondary outcome was MACE within 1 year after surgery. The authors used multivariable logistic regression to determine the adjusted association between the categories of stent type and percutaneous coronary intervention (PCI)-to-surgery interval with the primary and secondary outcomes.

Results:

Approximately 34% (n = 2,725) underwent stent insertion within 2 years before surgery, of whom 905 (33%) received drug-eluting stents (DES). For comparison, the investigators assembled a separate cohort of 341,350 surgical patients who had not undergone coronary revascularization. The primary outcome was 30-day MACE (mortality, readmission for ACS, 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 45-180 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 DES, the event rate was 1.2% once the interval exceeded 180 days, approaching that of intermediate-risk nonrevascularized individuals.

Conclusions:

The authors concluded that the earliest optimal time for elective surgery is 46-180 days after bare-metal stent implantation or >180 days after DES implantation.

Perspective:

The study reports that the risk of perioperative MACE was highest when major elective noncardiac surgery was performed <45 days after coronary stent implantation. Overall, the earliest optimal time for performing surgery appeared to be from 46-180 days after bare-metal stent implantation or >180 days after DES implantation. Thus, these findings may help inform clinical decision making regarding the timing of major elective noncardiac surgery after recent PCI. However, the decision of timing for elective surgery should be individualized, balancing the well-understood risks of restenosis with less certain risks of stent thrombosis, as well as patient anatomy, perioperative bleeding risks, and risks of delaying surgical procedures. Although surgery >180 days after DES may be reasonable in some non-ACS simple lesions with good acute results, data from the current study do not have sufficient size and scope to change current guidelines and recommend earlier surgery after DES, when there remain concerns regarding the residual risk of stent thrombosis within the first year.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Interventions and ACS, Chronic Angina

Keywords: Risk, Registries, Acute Coronary Syndrome, Surgical Procedures, Elective, Coronary Restenosis, Thrombosis, Drug-Eluting Stents, Canada, Hemorrhage, Logistic Models, Percutaneous Coronary Intervention


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