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Original Investigation
October 9, 2013

Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents

Author Affiliations
  • 1Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama
  • 2Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham
  • 3Department of Surgery, VA Boston Health Care System, Boston University and Harvard Medical School, Boston, Massachusetts
  • 4University of Colorado Health Outcomes Program and Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
  • 5VA Eastern Colorado Health Care System, Denver
  • 6University of Colorado, Denver
JAMA. 2013;310(14):1462-1472. doi:10.1001/jama.2013.278787
Abstract

Importance  Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 1 year after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). The evidence underlying these recommendations is limited and conflicting.

Objective  To determine risk factors for adverse cardiac events in patients undergoing noncardiac surgery following coronary stent implantation.

Design, Setting, and Participants  A national, retrospective cohort study of 41 989 Veterans Affairs (VA) and non-VA operations occurring in the 24 months after a coronary stent implantation between 2000 and 2010. Nonlinear generalized additive models examined the association between timing of surgery and stent type with major adverse cardiac events (MACE) adjusting for patient, surgery, and cardiac risk factors. A nested case-control study assessed the association between perioperative antiplatelet cessation and MACE.

Main Outcomes and Measures  A composite 30-day MACE rate of all-cause mortality, myocardial infarction, and cardiac revascularization.

Results  Within 24 months of 124 844 coronary stent implantations (47.6% DES, 52.4% BMS), 28 029 patients (22.5%; 95% CI, 22.2%-22.7%) underwent noncardiac operations resulting in 1980 MACE (4.7%; 95% CI, 4.5%-4.9%). Time between stent and surgery was associated with MACE (<6 weeks, 11.6%; 6 weeks to <6 months, 6.4%; 6-12 months, 4.2%; >12-24 months, 3.5%; P < .001). MACE rate by stent type was 5.1% for BMS and 4.3% for DES (P < .001). After adjustment, the 3 factors most strongly associated with MACE were nonelective surgical admission (adjusted odds ratio [AOR], 4.77; 95% CI, 4.07-5.59), history of myocardial infarction in the 6 months preceding surgery (AOR, 2.63; 95% CI, 2.32-2.98), and revised cardiac risk index greater than 2 (AOR, 2.13; 95% CI, 1.85-2.44). Of the 12 variables in the model, timing of surgery ranked fifth in explanatory importance measured by partial effects analysis. Stent type ranked last, and DES was not significantly associated with MACE (AOR, 0.91; 95% CI, 0.83-1.01). After both BMS and DES placement, the risk of MACE was stable at 6 months. A case-control analysis of 284 matched pairs found no association between antiplatelet cessation and MACE (OR, 0.86; 95% CI, 0.57-1.29).

Conclusions and Relevance  Among patients undergoing noncardiac surgery within 2 years of coronary stent placement, MACE were associated with emergency surgery and advanced cardiac disease but not stent type or timing of surgery beyond 6 months after stent implantation. Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated.

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