LETTER TO THE EDITOR
Percutaneous coronary intervention before noncardiac surgery: more threat than benefit?
Cesar E. Mendoza, MD,
Neerav Shah, MD and
Salim Virani, MD
Division of Cardiology, Jackson Memorial Hospital, University of Miami School of Medicine, 1611 NW 12th Ave. C402, Miami, Florida 33136, , USA
mendozatrauco{at}yahoo.com
We read with great interest the report by Wilson et al. (1) entitled "Clinical Outcome of Patients Undergoing Non-Cardiac Surgery in the Two Months Following Coronary Stenting." This very interesting study supports previous evidence that both percutaneous transluminal coronary angioplasty (PTCA) and coronary stenting increase adverse perioperative cardiac events (2–4).
In their study, the investigators reported that 8 (4%) of 207 patients undergoing noncardiac surgery (NCS) in the two months following successful coronary stenting had major adverse cardiac events. All 8 patients were among the 168 patients who underwent surgery within six weeks after coronary stent placement. No major events were observed in the remaining 39 patients undergoing surgery >6 weeks after stent placement. These data indicate that the risk of stent thrombosis is increased when surgery is carried out in the six weeks following the coronary intervention. In contrast to prior reports (3,4), Wilson et al. (1) did not identify an increased incidence of major hemorrhagic complications in the study population. As the researchers wisely stated in their study, the inability to determine a relationship among antiplatelet therapy, time to surgery, and bleeding should be interpreted with great caution. Large prospective studies will be necessary to clarify the results provided by the available small retrospective studies.
We recently performed a systematic review of the available literature in this regard (C. E. Mendoza et al., unpublished data, 2003). The main findings were: 1) the evidence supporting the use of PTCA prior to NCS as a strategy to lower the rate of perioperative adverse cardiac outcomes is limited and inconclusive; moreover, the largest reported study (2) showed serious adverse outcomes in patients subjected to NCS within 90 days of PTCA; and 2) coronary stenting performed shortly before NCS (especially during first two weeks) is associated with increased perioperative morbidity and mortality rates.
Antithrombotic therapy following percutaneous coronary intervention (PCI) in patients requiring NCS has to balance the risk of stent thrombosis against the risk of surgical bleeding. Systemic inflammatory and procoagulatory responses occur after PCI (5,6); these may be amplified by major NCS (7), thus increasing the risk of perioperative coronary thrombotic complications. Therefore, an antithrombotic regimen effective in the nonsurgical setting may not be effective to prevent stent thrombosis, but it may be sufficient to cause major surgical bleeding. Until further data are available, NCS following PCI should be deferred whenever possible for at least four weeks, allowing the completion of currently recommended antiplatelet therapy to prevent the thrombotic complications associated with PCI.
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References
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1. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42:234–240[Abstract/Free Full Text]
2. Posner KL, Van Norman GA, Chan V. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analg. 1999;89:553–560[Abstract/Free Full Text]
3. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35:1288–1294[Abstract/Free Full Text]
4. Sharma AK, Ajani AE, Manias P, et al. Coronary angioplasty with stenting preceding major noncardiac surgery: when is it safe to operate (abstr)? J Am Coll Cardiol. 2003;41(Suppl A):20A
5. Azar RR, McKay RG, Kiernan FJ, et al. Coronary angioplasty induces a systemic inflammatory response. Am J Cardiol. 1997;80:1476–1489[CrossRef][Medline]
6. Lins M, Zurborn KH, Dau O, et al. Coagulation activation in patients undergoing directional coronary atherectomy. Thromb Res. 1997;86:433–441[CrossRef][Medline]
7. Bradbury A, Adam D, Garrioch M, Brittenden J, Gillies T, Ruckley CV. Changes in platelet count, coagulation and fibrinogen associated with elective repair of asymptomatic abdominal aortic aneurysm and aortic reconstruction for occlusive disease. Eur J Vasc Endovasc Surg. 1997;13:375–380[CrossRef][Medline]
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H.-J. Priebe
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