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How to Evaluate Patients With Preoperatively Implanted Coronary Stents for Non-cardiac Surgery?

How to Evaluate Patients With Preoperatively Implanted Coronary Stents for Non-cardiac Surgery?

With the progress of aging, the number of patients with preoperative cardiovascular disease is gradually increasing, especially some patients with coronary heart disease and previous implantation of coronary stents. Thoracic surgery is one of the high-risk specialized operations. How to correctly evaluate and prepare for this kind of patients.


1. Cardiovascular products coronary stents are widely used


Although the guidelines recommend postponing noncardiac surgery after percutaneous coronary intervention (PCI), 3.5% or more patients underwent noncardiac surgery within 6 months after stent implantation.


It is noteworthy that patients who underwent surgery within one year after percutaneous coronary intervention had a significantly increased risk of perioperative adverse events compared with patients without coronary stents (respectively 8.9% and 1.5%; adjusted or was 2.6 [95% confidence interval: 1.4 ~ 4.9]; P < 0.001).


The risk of ischemic events is inversely proportional to the time between stent implantation and non cardiac surgery, and is directly related to the early discontinuation of dual antiplatelet therapy. In some cases, patients may have stent thrombosis and myocardial infarction during perioperative period.


Whether patients undergoing coronary stent implantation should postpone surgery should comprehensively weigh the relationship between "risk associated with delayed surgery" and "thrombotic risk caused by stopping dual antiplatelet therapy".


2. Postoperative analysis of coronary stent implantation of cardiovascular products


A large sample study of American veterans included 28029 patients who underwent 41989 operations. The results showed that the incidence of major adverse cardiovascular events or death (MACE) was 11.6%; The incidence of MACE was 6.4% between 6weeks and 6 months after PCI; The incidence of MACE was 4.2% from 6 months to 1 year after PCI, while the incidence of MACE was 3.5% one year after PCI.


Non-cardiac surgery should be postponed as far as possible within 2 weeks after coronary balloon dilatation, 30 days after bare metal stent implantation, or 12 months after drug-eluting stent implantation. Although some studies believe that it may be safe to perform surgery within 3 to 6 months or more after drug-eluting coronary stent implantation, the current guidelines do not recommend it.


For patients with drug-eluting stents implanted for 6 months or more, surgeons and anesthesiologists must determine whether the risk of further delayed surgery will be greater than the expected risk of myocardial infarction and stent thrombosis while considering the variable "time".


After coronary stent implantation of cardiovascular products, the American Heart Association (AHA) and the American College of Cardiology (ACC) all recommend continued use of aspirin for antiplatelet therapy, while European guidelines prefer to make individualized decisions based on the risk of bleeding and thrombosis.


Post hoc analysis from a large sample study (POISE-2) showed that perioperative use of aspirin in patients undergoing noncardiac surgery after coronary stent implantation was associated with a reduction in 30 day mortality or nonfatal myocardial infarction (6.0% in the aspirin group vs 11.5% in the non-aspirin group; hazard ratio 0.50 [95% confidence interval: 0.26 ~ 0.95]).


For patients with coronary stent implantation, the perioperative risk factors were evaluated as follows:


Timing of coronary stent implantation and other factors


Time from PCI to non cardiac surgery

<3 months

3-6 months


6-12 months


>12 months


Types of coronary stents

drug eluting stent

bare metal support


Coronary lesions and stent length

relatively long

relatively short

Original evidence of PCI

acute coronary syndrome

stable coronary syndrome


Patient age and complications


Age

older (≥ 60 years old)

younger (< 60 years old)

Heart failure

yes


no

Renal function GFR

<30mL/min


≥30mL/min


Hemoglobin level

<10g/dL

≥10g/dL



Surgical factors


Cardiovascular risk factors caused by surgery


High risk surgery

Low risk surgery

Risk of surgery related bleeding

high

low

Urgency of operation

Emergency operation

Elective surgery

Color classification (hazard level)


High risk

Medium risk

Low risk



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