CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Harm H.H. Feringa, MD,
Olaf Schouten, MD,
Anai E.S. Durazzo, MD and
Don Poldermans, MD, PhD*
* Department of Anesthesiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands (Email: d.poldermans{at}erasmusmc.nl).
We would like to thank Dr. Steg and Dr. Marques and colleagues for their interest regarding our recent study (1). The more widespread use of drug-eluting stents will have its implications in perioperative management of patients undergoing noncardiac surgery. Especially in the early phase after stent implantation, patients are at increased risk, either owing to bleeding complications in those who continued dual antiplatelet therapy or because of in-stent thrombosis after antiplatelet discontinuation. These patients might be identified by troponin elevation and abrupt ST-segment elevation in the territory of a recently implanted stent. Although it is recommended to continue antiplatelet therapy in this period during surgery, no convincing safety data exists.
Our report demonstrates that preoperative coronary revascularization in 49 high-risk patients was not associated with an improved outcome compared with medical therapy. Of this group, a percutaneous coronary intervention was performed in 32 patients, and a drug-eluting stent was used in 30 patients. Of these patients, a Q-wave myocardial infarction occurred in 11. Continuous 12-lead electrocardiographic monitoring was performed in a substudy for the detection of non–Q-wave ST-segment changes, which may be present in up to 41% of patients and have prognostic implications (2,3). Of the 11 patients with Q-wave myocardial infarction, ST-segment elevation occurred in 7. The location of ST-segment elevation corresponded to the recently stented coronary artery territory in 5 of those 7 patients. Importantly, all stented patients underwent surgery using dual antiplatelet therapy.
One might speculate that the increased thrombotic risk during surgery as a result of cytokine response, catecholamine surge, platelet activation, and reduced fibrinolytic activity can not be prevented by dual platelet therapy.
How are we to treat these high-risk patients with a progressive aortic aneurysm or critical limb ischemia? There are several options. The suggestion of Dr. Marques and colleagues to refrain from surgery if possible should indeed be considered. However, the population studied had a clear indication for surgery. Because cardiac outcome immediately after surgery was not improved by prophylactic revascularization in this small study, a switch to postoperative coronary revascularization could be considered in this high-risk population. The indications for coronary revascularization in this population after surgery are similar to the generally accepted indications for revascularization provided by the American College of Cardiology/American Heart Association guidelines (4). Furthermore, in selected patients with an urgent need for surgery, endovascular repair with a relatively low perioperative mortality rate is a promising option (5). In a group of 2,368 high-risk patients based on clinical risk factors, 788 were scheduled for endovascular repair, with a 30-day mortality rate of 3.4%. If these promising results can be confirmed in patients with high-risk coronary anatomy as well, endovascular repair should be considered in this population as the treatment of choice.
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References
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- Poldermans D, Schouten O, Vidakovic R, et al. DECREASE Study Group A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V pilot study J Am Coll Cardiol 2007;49:1763-1769.[Abstract/Free Full Text]
- Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery N Engl J Med 1990;323:1781-1788.[Abstract]
- Feringa HH, Bax JJ, Boersma E, Kertai, MD, et al. High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients Circulation 2006;114:SI344-SI349.
- Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina) J Am Coll Cardiol 2003;41:159-168.[Free Full Text]
- Bush RL, Johnson ML, Hedayati N, Henderson WG, Lin PH, Lumsden AB. Performance of endovascular aortic aneurysm repair in high-risk patients: results from the Veterans Affairs National Surgical Quality Improvement Program J Vasc Surg 2007;45:227-233.[CrossRef][ISI][Medline]
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