MOFFITT CARDIOLOGY REPORT PEARLS 5/30/17: Non-Cardiac Surgery after DES-PCI!

Hey Everyone! Thanks to James for sharing the case of a middle-aged man on DAPT after an NSTEMI who required amputation for chronic osteomyelitis. We discussed several issues around DAPT and surgery. Pearls below!

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Top Pearls:

  1. Up to 34% of patients undergoing DES-PCI will need non-cardiac surgery within 12 months after stent placement!
  2. Current guidelines strongly advise against performing non-cardiac surgery < 3 months after DES-PCI and recommending delaying past 6-12 months if possible.
  3. In a recent observational study, the increased risk of cardiac and all-cause mortality after surgery only held true if surgery was performed <1 month after DES-PCI, suggesting that non-cardiac surgery might be safe as soon as 1 month after DES-PCI.

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For those who want more info:

5-34% of patients undergoing DES-PCI will need non-cardiac surgery within 12 months after stent placement. (JACC 2016;68:2633-6).

Current U.S. guidelines recommend delaying non-cardiac surgery for 12 months after DES-PCI, but state surgery may be considered within 3-6 months (with discontinuation of DAPT) if the risk of surgical delay exceeds that of stent thrombosis. The guidelines strongly advise against surgery < 3 months after DES-PCI (ACC/AHA guidelines, JACC 2016;68:1082-115).

Here’s a recent study arguing that surgery could be considered sooner than current guidelines recommend:

*Ergholm G et al, Risk associated with surgery within 12 months after coronary DES implantation, JACC 2016;68:2622-32. https://doi.org/10.1016/j.jacc.2016.09.967

Summary: Observational study of 4,303 Danish patients who underwent DES-PCI followed by surgery within 12 months, compared to 20,232 controls undergoing similar surgical procedures. Patients requiring surgery after DES-PCI had increased risk of MI, cardiac death, and all-cause mortality compared to controls, but the increased risk in this study was only present within the first month after DES-PCI, suggesting that surgery might be undertaken earlier than currently recommended.

Central figure from article: Only patients who had a time from PCI to surgery of < 1 month had significantly increased MI, cardiac death, and all-cause mortality at 30 days after surgery compared to controls.

Figure

Conclusion: The authors conclude that non-cardiac surgery could be considered as soon as 1 month after DES-PCI. An accompanying article (https://doi.org/10.1016/j.jacc.2016.09.960) notes that data from a single registry may not be sufficient to change guidelines, but this study does provide data to support the safety of truly necessary non-cardiac surgery performed earlier than current guidelines recommend.

 

References:

Egholm G et al, Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. JACC 2016;68:2622-32. https://doi.org/10.1016/j.jacc.2016.09.967

Spaulding C and Mennuni MG, Surgery after DES implantation: to operate or not to operate: is it still a question? JACC 2016;68:2633-6. https://doi.org/10.1016/j.jacc.2016.09.960

Levine GN et al, 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. JACC 2016;68:1082-115. https://doi.org/10.1016/j.jacc.2016.03.513

 

Evernote: https://www.evernote.com/shard/s272/sh/3c0246a4-b66c-4583-913a-b386010007e3/b3aec87d5783d83600177504adebc172

 

Have a great day everyone!

SamMy

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2 thoughts on “MOFFITT CARDIOLOGY REPORT PEARLS 5/30/17: Non-Cardiac Surgery after DES-PCI!”

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