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Invited Commentary
May 2016

Add Indication for Coronary Stent as a Risk Factor for Poor Outcome Following Noncardiac Surgery

Author Affiliations
  • 1Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville
JAMA Surg. 2016;151(5):469-470. doi:10.1001/jamasurg.2015.4662

In this study by Holcomb and colleagues,1 the authors examined 26 661 patients over 10 years who had a coronary stent placed for 1 of 3 indications: (1) myocardial infarction (MI), (2) unstable angina, and (3) revascularization not associated with acute coronary syndrome. The authors then linked postoperative composite outcomes described as major adverse cardiac events (MACE) with clinical indication for coronary stenting in the 24 months following stent placement. The 3 groups were well matched in terms of size and demographics. The most important finding of this work is that postoperative MACE rates were significantly higher in the MI indication group (7.5%) compared with the other 2 groups. In fact, when surgery occurred within 3 months of coronary stent placement, the adjusted odds ratio of MACE was 5.25 (95% CI, 4.08-6.75) compared with the group with revascularization not associated with acute coronary syndrome. While the risk of MACE decreased over time, the rates remained higher out to 24 months for the MI group. In contrast to what is standard practice (ie, waiting an entire year to stop double antiplatelet therapy [DAPT] and intervene on a patient with a drug-eluting stent), the authors found in this cohort that stent type was not predictive of MACE. They concluded by suggesting that delaying elective noncardiac surgery to 6 months in the MI cohort of patients may be important regardless of stent type. In addition, while the impact is not as great, waiting a full 24 months for noncardiac surgery would still be beneficial (Figure 2 and the eFigure in the Supplement in the Holcomb et al article1) in terms of reducing MACE and MI alone.