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Figure.
Percentage of Surgery Cancellations Related to Death or Myocardial Infarction (MI) Among All Surgery Cancellations by Time Since Coronary Stent Placement
Percentage of Surgery Cancellations Related to Death or Myocardial Infarction (MI) Among All Surgery Cancellations by Time Since Coronary Stent Placement
Table.  
Characteristics of Cancelled Surgical Procedures Overall and by Time Since Coronary Stent Placement
Characteristics of Cancelled Surgical Procedures Overall and by Time Since Coronary Stent Placement
1.
Fleisher  LA, Fleischmann  KE, Auerbach  AD,  et al.  2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245.
PubMedArticle
2.
van Kuijk  JP, Flu  WJ, Schouten  O,  et al.  Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents. Am J Cardiol. 2009;104(9):1229-1234.
PubMedArticle
3.
Hawn  MT, Graham  LA, Richman  JS, Itani  KM, Henderson  WG, Maddox  TM.  Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310(14):1462-1472.
PubMedArticle
4.
Holcomb  CN, Graham  LA, Richman  JS,  et al.  The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64(25):2730-2739.
PubMedArticle
5.
Argo  JL, Vick  CC, Graham  LA, Itani  KM, Bishop  MJ, Hawn  MT.  Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg. 2009;198(5):600-606.
PubMedArticle
6.
Rassi  AN, Yeh  RW.  Cardiovascular event risk after noncardiac surgery. JAMA. 2014;311(5):525.
PubMedArticle
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Research Letter
Association of VA Surgeons
December 2015

Frequency of Surgery Cancellations Associated With Myocardial Infarction or Death 6 Months After Coronary Stent Placement

Author Affiliations
  • 1Birmingham VA Medical Center, Birmingham, Alabama
  • 2Department of Surgery, University of Alabama at Birmingham
  • 3Department of Surgery, Stanford University, Stanford, California
JAMA Surg. 2015;150(12):1199-1201. doi:10.1001/jamasurg.2015.3078

Observational studies report a decreased risk of postoperative adverse cardiac events among patients following percutaneous coronary intervention (PCI) when surgery is more than 6 months after coronary stent placement14; however, the frequency and timing of surgery cancellations due to preoperative adverse cardiac events or death in the interval between the scheduling of the procedure and the procedure itself is unknown. Changes in medical condition may account for 28% of surgery cancellations.5 In addition, prior research on adverse postoperative events may be biased by the unavoidable selection criterion that a patient must first experience surgery in order to be studied.6 With little information on the frequency and factors associated with surgery cancellations following PCI, it is difficult to quantify the impact of this bias. We hypothesize that surgery cancellations are more frequent in the first 6 months following the placement of a drug-eluting stent (DES) and that a higher proportion of early cancellations are associated with acute myocardial infarction (MI) or death.

Methods

The study cohort includes all patients receiving a PCI within the Veterans Affairs (VA) Healthcare System from fiscal year 2000-2010. The study was granted institutional review board approval with a waiver of informed consent at the Birmingham VA Medical Center. Data on PCIs were linked with the VA Surgical Package to identify all scheduled noncardiac surgical procedures occurring in the 2 years following PCI. Surgery cancellations were then identified among the scheduled surgical procedures using the VA Surgical Package, and the VA Medical Statistical Analysis Software (SAS) files were queried for instances of acute MI not related to the PCI (International Classification of Diseases, Ninth Revision, Clinical Modification codes 410.x1) or death within 30 days of a cancelled surgery date. The VA Medical SAS files were used to define demographics and other comorbidities present at the time of stent placement. The characteristics of the scheduled surgical procedures were compared using χ2 test statistics. Analyses were then limited to only cancelled surgical procedures, and the characteristics of cancellations related to MI or death were examined using the χ2 test.

Results

Of the 33 046 scheduled noncardiac surgical procedures within 2 years of PCI, 4387 (13.3%) were cancelled, with 46.7% of these cancelled surgical procedures proceeding to subsequent surgery (47.2% to DES placement and 46.2% to bare metal stent [BMS] placement; P = .53). Cancellations were more frequent among patients with a BMS (14.2%) than among patients with a DES (12.4%) (P < .001) and were highest among patients with a history of chronic kidney disease (16.6%; P < .001) or a recent episode of congestive heart failure (16.0%; P < .001). They were also more common for planned digestive (23.3%) or vascular (17.1%) procedures (P < .001; Table). Cancellation rates were highest in the first 6 months following stent placement (15.1% for <6 months vs 12.6% for >6 months; P < .001) and remained significantly elevated among patients with a BMS beyond 6 months (13.5% of patients with a BMS vs 11.8% of patients with a DES; P < .001).

Death or an MI diagnosis accompanied 6.0% of cancellations (4.2% of completed surgical procedures; P < .001) and was more frequent among cancellations within 6 months following PCI (8.5%) compared with those beyond 6 months (4.9%) (P < .001; Figure). Cancellations related to MI or death were more frequent among patients whose stent was placed for an MI (9.4%; P < .001) and among planned respiratory (10.4%) or vascular procedures (8.7%) (P < .001). The proportion of cancellations related to death or MI did not vary by stent type (5.9% with DES vs 5.9% with BMS; P > .99).

Discussion

This research addresses the important gap of potential selection bias in the current literature examining adverse postoperative outcomes among patients experiencing PCI.6 One limitation of our study is that a surgery must first be scheduled in order to be cancelled, so we are likely underestimating the magnitude of cancellations. To conclude, we found that surgery cancellations were most frequent in the 6 months after PCI and that these cancellations were more likely to be associated with a diagnosis of acute MI or death. These results are consistent with prior findings of an increased risk of cardiac events in the 6 months following PCI regardless of surgery4 and further support planning of elective surgery at least 6 months after PCI.

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Article Information

Corresponding Author: Mary T. Hawn, MD, MPH, Stanford University, 300 Pasteur Dr, M121 Alway Bldg, Stanford, CA 94306 (mhawn@stanford.edu).

Published Online: October 7, 2015. doi:10.1001/jamasurg.2015.3078.

Author Contributions: Dr Hawn had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Graham, Hollis, Hawn.

Acquisition, analysis, or interpretation of data: Graham, Hollis, Richman.

Drafting of the manuscript: Graham.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Graham, Richman.

Obtained funding: Hawn.

Administrative, technical, or material support: Graham.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this study was provided by the Department of Veteran Affairs Health Services Research and Development grant IIR 09-347.

Role of the Funder/Sponsor: The Department of Veteran Affairs had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views the Department of Veterans Affairs or the US government.

Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 4, 2015; Miami Beach, Florida.

References
1.
Fleisher  LA, Fleischmann  KE, Auerbach  AD,  et al.  2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245.
PubMedArticle
2.
van Kuijk  JP, Flu  WJ, Schouten  O,  et al.  Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents. Am J Cardiol. 2009;104(9):1229-1234.
PubMedArticle
3.
Hawn  MT, Graham  LA, Richman  JS, Itani  KM, Henderson  WG, Maddox  TM.  Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310(14):1462-1472.
PubMedArticle
4.
Holcomb  CN, Graham  LA, Richman  JS,  et al.  The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64(25):2730-2739.
PubMedArticle
5.
Argo  JL, Vick  CC, Graham  LA, Itani  KM, Bishop  MJ, Hawn  MT.  Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg. 2009;198(5):600-606.
PubMedArticle
6.
Rassi  AN, Yeh  RW.  Cardiovascular event risk after noncardiac surgery. JAMA. 2014;311(5):525.
PubMedArticle
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