LETTER TO THE EDITOR
Coronary stenting or percutaneous transluminal coronary angioplasty prior to noncardiac surgery increases adverse perioperative cardiac events: the evidence is mounting
Gail A. Van Norman, MDa and
Karen Posner, PhDb
a Assistant Professor, Department of Anesthesiology, Acting Chief, Cardiothoracic Anesthesiology, University of Washington, Seattle, Washington, USA
b Research Associate Professor, Department of Anesthesiology, University of Washington, Seattle, Washington, USA
The findings of Kalusa et al. (1) support previous evidence that coronary manipulation <90 days before noncardiac surgery (NCS) does not benefit, and may actually harm, patients with coronary disease. In 1997, the American College of Physicians concluded that prophylactic coronary revascularization before NCS had not been shown to decrease short-term mortality (2). They stated that the need for revascularization in such patients should be determined on the same clinical grounds as it would be if they were not undergoing NCS, and that without such indications, patients should proceed directly to surgery. Based on lack of reasonable data supporting preoperative angioplasty, they made similar recommendations regarding prophylactic percutaneous transluminal coronary angioplasty (PTCA), echoing previously published findings of the American College of Cardiology (3).
We retrospectively studied 686 patients who underwent PTCA before NCS, 686 matched surgery patients with uncorrected coronary artery disease (CAD) and 2,155 matched normal control subjects (4). Patients undergoing PTCA had twice the rate of adverse cardiac outcomes as normal subjects, seven times the rate of angina, almost four times the rate of myocardial infarction (MI) and twice the rate of congestive heart failure (CHF). Twenty-six percent of the patients who underwent PTCA <90 days before NCS had adverse cardiac outcomes. The odds ratio of adverse cardiac outcome, angina, CHF and MI in patients with PTCA <90 days before NCS, compared to normal subjects, were 2.8, 26.0, 2.4 and 34.0, respectively. Patients who underwent PTCA within 90 days of NCS suffered twice the rate of perioperative MI compared with patients with uncorrected CAD. Mason et al. (5) and Fleisher et al. (6) found that patients with CAD undergoing vascular surgery without coronary intervention had better outcomes than patients who were revascularized. For nonvascular surgery patients, the risk-to-benefit ratio of coronary revascularization is probably even poorer than these studies suggest, due to lower baseline risks of adverse cardiac outcomes.
Elmore et al. (7) and Huber et al. (8) are often cited as support that PTCA before NCS is "safe." But Elmore et al. (7) reviewed only 14 patients who had PTCA before NCS, and Huber et al. (8) studied only 50. Neither study is of sufficient size or design to warrant conclusions regarding outcomes in patients who had PTCA versus those who did not. Neither study examined timing of PTCA and NCS.
Systemic autoimmune and inflammatory responses occur after PTCA and stenting, with elevations in C-reactive protein, serum amyloid type A, antinuclear factor and platelet adhesive molecule expression (9–11). Changes persist up to three weeks following PTCA (12). Activation of coagulation and fibrinolysis also occur (13). Restimulation of the autoimmune, inflammatory, coagulation and fibrinolytic systems during NCS may amplify both bleeding and thrombotic complications when surgery occurs soon after coronary intervention.
Several reports suggest that PTCA or stenting increases risks of adverse cardiac outcomes for some patients who undergo subsequent NCS. Until we know more, prophylactic PTCA and stenting prior to NCS should be undertaken with extreme caution if surgery will occur within 90 days. Elective surgery should be postponed whenever possible for a 40- to 90-day waiting period after coronary intervention.
 |
References
|
|---|
1. Kalusa GL, Joseph J, Lee J, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35:1288–1294[Abstract/Free Full Text]
2. Palda VA, Detsky A. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med. 1997;127:313–328[Abstract/Free Full Text]
3. Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996;27:910–948[CrossRef][Medline]
4. Posner K, Van Norman G. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analog. 1999;89:553–560[Abstract/Free Full Text]
5. Mason JJ, Owens DK, Harris RA, et al. The role of coronary angiography and coronary revascularization before noncardiac vascular surgery. JAMA. 1995;273:1919–1925[Abstract/Free Full Text]
6. Fleisher LA, Eagle KA, Shaffer T, et al. Mortality after major vascular surgery: analysis of the Medicare database. (abstr)Anesth Anal. 1997;84:SCA43
7. Elmore JR, Hallett JW, Gibbons R, et al. Myocardial revascularization before abdominal aortic aneurysmorrhaphy: effect of coronary angioplasty. Mayo Clin Proc. 1991;68:713–715
8. Huber K, Evans MA, Bresnahan J, et al. Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clin Proc. 1992;67:15–21[Medline]
9. Blum A, Vardinon N, Kaplan G, et al. Autoimmune and inflammatory responses may have an additive effect in post percutaneous transluminal coronary angioplasty restenosis. Am J Cardiol. 1998;81:339–341[CrossRef][Medline]
10. Serrano CV Jr, Ramires JA, Venturinelli M, et al. Coronary angioplasty results in leukocyte and platelet activation with adhesion molecule expression: evidence of inflammatory response in coronary angioplasty. J Am Coll Cardiol. 1997;29:1276–1283[Abstract]
11. Azar RR, McKay RG, Kiernan FJ, et al. Coronary angioplasty induces a systemic inflammatory response. Am J Cardiol. 1997;80:1476–1489[CrossRef][Medline]
12. Kamijikkoku S, Murohara T, Tayama S, et al. Acute myocardial infarction and increased soluble intercellular adhesion molecule-1: a marker of vascular inflammation and a risk of early restenosis? Am Heart J. 1998;136:231–236[CrossRef][Medline]
13. Lins M, Zurborn KH, Dau O, et al. Coagulation activation in patients undergoing directional coronary atherectomy. Thromb Res. 1997;86:433–441[CrossRef][Medline]
This article has been cited by other articles:
|
|
|
|
 
N. Bonaros, D. Hennerbichler, G. Friedrich, A. Kocher, O. Pachinger, G. Laufer, and J. Bonatti
Increased mortality and perioperative complications in patients with previous elective percutaneous coronary interventions undergoing coronary artery bypass surgery
J. Thorac. Cardiovasc. Surg.,
April 1, 2009;
137(4):
846 - 852.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Thielmann, R. Leyh, P. Massoudy, M. Neuhauser, I. Aleksic, M. Kamler, U. Herold, J. Piotrowski, and H. Jakob
Prognostic Significance of Multiple Previous Percutaneous Coronary Interventions in Patients Undergoing Elective Coronary Artery Bypass Surgery
Circulation,
July 4, 2006;
114(1_suppl):
I-441 - I-447.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. N. Vicenzi, T. Meislitzer, B. Heitzinger, M. Halaj, L. A. Fleisher, and H. Metzler
Coronary artery stenting and non-cardiac surgery--a prospective outcome study
Br. J. Anaesth.,
June 1, 2006;
96(6):
686 - 693.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. T. Murphy and B. G. Fahy
Thrombosis of Sirolimus-Eluting Coronary Stent in the Postanesthesia Care Unit
Anesth. Analg.,
October 1, 2005;
101(4):
971 - 973.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
Top
References