Increased elective surgical risk limited to the first month after PCI
medwireNews: The high risk of adverse events associated with elective noncardiac surgery after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation may be limited to the first month after the procedure, study results suggest.
Current European and US guidelines on noncardiac procedures “recommend delaying surgery after DES-PCI for 6 to 12 months,” explain Gro Egholm (Aarhus University Hospital, Denmark) and study co-authors.
“Our results suggest that surgery after DES-PCI might be performed earlier without increased risk,” they add.
In an analysis of Danish registries, the researchers found that among patients undergoing noncardiac surgery, 1.5% of 4303 patients who underwent prior PCI experienced myocardial infarction (MI) within 30 days of surgery, compared with 0.2% of 20,207 matched patients without prior stent implantation (odds ratio [OR]=7.48 after adjustment for factors including emergency surgery and comorbidities).
Although the participants were matched for factors including the specific surgical procedure and urgency of the operation, patients with ischemic heart disease (IHD) had more comorbidities than those without, with 76.9% versus 27.6% having at least one comorbidity.
Prior PCI was also associated with an increased risk for cardiac death after surgery, with rates of 1.1% versus 0.2% (adjusted OR=7.51), but not with all-cause mortality (3.2 vs 2.7%; adjusted OR=1.07).
When the team stratified their results by time, PCI was associated with a significantly increased risk of events only in patients undergoing surgery within 1 month of PCI. MI rates according to the time of surgery from the first PCI conducted during the study were 7.2% versus 0.5% at less than 1 month, 1.4% versus 0.5% at 1–2 months, and 0.4% versus 0.8% at 2–12 months. The corresponding rates of cardiac death were 5.0% versus 0.3%, 0.4% versus 0.2%, and 0.4% versus 0.1%.
The overall mortality risk was also higher in PCI-treated patients who underwent surgery within 1 month compared with matched patients without ischemic heart disease (9.0 vs 7.0%), but beyond the first month after stent implantation, those who had undergone PCI had “a low and similar risk” of mortality compared with those who had not.
However, the increased risk seen in IHD patients who underwent surgery within 1 month of stenting was also observed, to a lesser degree, in their matched non-IHD controls, who underwent similar operations with a similar degree of urgency, indicating that “part of the increased risk was related to the type and urgency of surgery and not solely explained by surgery early after PCI,” say the authors in the Journal of the American College of Cardiology.
In an accompanying commentary, Christian Spaulding and Marco Mennuni (both from Paris Descartes University, France) note that “[d]ata from a single registry will probably not be enough to modify current guidelines,” but that the study adds “an important component to the difficult decision-making process for noncardiac surgery after DES-PCI.”
“A green (or at least cautionary yellow) light may be given based on consensus between cardiologists, anesthesiologists, and surgeons after balancing the need for surgery, risk of stent thrombosis, and bleeding risks,” they believe, concluding that “if surgery cannot be delayed, it can probably be performed safely 1 month after DES-PCI in selected patients.”
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