The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting

Background Recent coronary stent placement and noncardiac surgery contribute to the risk of adverse cardiac events, but the relative contributions of these two factors have not been quantified.Objectives This research was designed to determine the incremental risk of noncardiac surgery on myocardial infarction(MI) and coronary revascularization following coronary stenting.Methods A U.S. retrospective cohort study of patients receiving coronary stents at Veterans Affairs medical centers between 2000 and 2010 was used to match patients undergoing noncardiac surgery within 24 months of stent placement to two patients with stents not undergoing surgery. Patients were matched on stent type and cardiac risk factors present at the time of stent placement. A composite endpoint of MI and / or cardiac revascularization for the 30-day interval post-surgery was calculated. Adjusted risk differences(RD) were compared across time periods following stent implantation, using generalized estimating equations.Results We matched 20,590 surgical patients to 41,180 nonsurgical patients. During the 30-day interval following noncardiac surgery, the surgical cohort had higher rates of the composite cardiac endpoint(3.1% vs. 1.9%;RD: 1.3%; 95% confidence interval: 1.0% to 1.5%). The incremental risk of noncardiac surgery adjusted for surgical characteristics ranged from 3.5% immediately following stent implantation to 1% at 6 months, after which it remained stable out to 24 months. Factors associated with a significant reduction in risk following surgery more than 6 months post-stent included elective inpatient procedures(ΔRD: 1.8%; P = 0.01), highrisk surgery(ΔRD: 3.7%; P = 0.01), and drug-eluting stent(DES)(ΔRD: 1.3%; P = 0.01).Conclusions The incremental risk of noncardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilizes at 1.0% after 6 months. Elective, high-risk,inpatient surgery, and patients with DES may benefit most from delay from a 6-month delay after stent placement.(From: Journal of the American College of Cardiology Volume 64, Issue 25, 30 December 2014, Pages 2730-2739)     

Risks of noncardiac surgery after coronary stenting

An increased risk of major complications for noncardiac surgery after coronary stenting has been suggested. We retrospectively reviewed all cases of coronary stents from 1999 to 2003 with subsequent surgery to assess major adverse cardiovascular events (MACEs), including myocardial infarction, stent thrombosis, major bleeding, and death. Among the 56 patients identified, 8 developed MACEs; 38% underwent surgery < or =14 days after stenting, and 62% underwent surgery 15 to 42 days after stenting. No patient developed MACEs if surgery occurred >42 days after stenting. Among patients who developed MACEs, 77% of surgeries were elective, 19% were urgent, and only 4% were emergency. Noncardiac surgery 6 weeks after coronary stenting is associated with a high risk of MACEs.     

Catastrophic outcomes of noncardiac surgery soon after coronary stenting

OBJECTIVES: To assess the clinical course of patients who have undergone coronary stent placement less than six weeks before noncardiac surgery. BACKGROUND: Surgical and percutaneous transluminal coronary angioplasty revascularization performed before high-risk noncardiac surgery is expected to reduce perioperative cardiac morbidity and mortality. Perioperative and postoperative complications in patients who have undergone coronary stenting before a noncardiac surgery have not been studied. METHODS: Forty patients who underwent coronary stent placement less than six weeks before noncardiac surgery requiring a general anesthesia were included in the study (1-39 days, average: 13 days). The records were screened for the occurrence of adverse clinical events, including myocardial infarction, stent thrombosis, peri- and postoperative bleeding and death. RESULTS: In 40 consecutive patients meeting the study criteria, there were seven myocardial infarctions (MIs), 11 major bleeding episodes and eight deaths. All deaths and MIs, as well as 8/11 bleeding episodes, occurred in patients subjected to surgery fewer than 14 days from stenting. Four patients expired after undergoing surgery one day after stenting. Based on electrocardiogram, enzymatic and angiographic evidence, stent thrombosis accounted for most of the fatal events. The time between stenting and surgery appeared to be the main determinant of outcome. CONCLUSIONS: Postponing elective noncardiac surgery for two to four weeks after coronary stenting should permit completion of the mandatory antiplatelet regimen, thereby reducing the risk of stent thrombosis and bleeding complications.     

Major noncardiac surgery following coronary stenting: When is it safe to operate?

The optimal timing for elective noncardiac surgery (NCS) after coronary stenting is uncertain. We identified 47 patients who underwent elective NCS within 90 days of coronary stent placement between January 1995 and December 2000. Twenty-seven patients had NCS within 3 weeks of coronary stenting. Six of the seven in whom thienopyridine antiplatelet therapy was discontinued died postoperatively in a manner suggestive of stent thrombosis. In contrast, only 1 of the 20 patients in whom the thienopyridine was continued through the NCS died. The frequency of perioperative hemorrhage was similar whether or not the antiplatelet agent was continued. Only 1 perioperative death occurred in the 20 patients with NCS more than 3 weeks following stenting.     

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: Results of a French multicenter registry

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous tranluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min ± 406 min vs. 170 min ± 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5 %) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery. Cathet. Cardiovasc. Intervent. 48:441–448, 1999. © 1999 Wiley-Liss, Inc.     

Comparison of outcomes of coronary stenting versus conventional coronary angioplasty in the department of veterans affairs medical centers

Although the short-term benefits of stent deployment have been established, less is known about long-term outcomes. This study compares short- and long-term outcomes in veterans undergoing stenting and conventional coronary angioplasty. We used Department of Veterans Affairs databases to identify 27,224 veterans who had undergone percutaneous coronary intervention (PCI) in Veterans Affairs medical centers between October 1994 and September 1999. Patients were classified according to whether they had acute myocardial infarction (AMI) as the principal diagnosis. Baseline characteristics were similar in the stent and conventional groups. In AMI, hospital mortality was 2.9% for those with stents and 4.8% for those who underwent conventional coronary angioplasty (p <0.0001), whereas for patients without AMI, hospital mortality was similar (1.2% vs 1.4%, p = 0.12). For AMI, same-admission bypass surgery rates were lower in the stent group (0.7% vs 3.2%, p <0.0001) and in the group without AMI (1.2% vs 3.3%, p <0.0001). Two-year survival was better for stenting in veterans with (90% vs 88%, p = 0.006) and without (92% vs 91%, p = 0.008) AMI. For AMI, 2-year rehospitalization rates for PCI (10% vs 13%, p <0.0001), coronary artery bypass surgery (4% vs 6%, p <0.0001), and unstable angina (17% vs 23%) were lower for those who had stenting. In the no-AMI group, 2-year rehospitalization rates for PCI (14% vs 17%, p <0.0001), coronary artery bypass surgery (5% vs 8%, p <0.0001), and unstable angina (22% vs 29%, p <0.0001) were lower in the stent group. Veterans who underwent stenting had lower hospital mortality, reduced rates of same-admission bypass surgery, marginally better survival, and lower rates of rehospitalization than their counterparts who had conventional coronary angioplasty.     

Cardiac outcome of major noncardiac surgery in patients undergoing preoperative coronary angioplasty

Patients with significant coronary artery disease are at increased risk for myocardial infarction and death when undergoing major noncardiac surgery, particularly vascular, thoracic and upper abdominal procedures. Revascularization with coronary bypass surgery has shown to be effective in reducing perioperative coronary events in such patients. Little data is available on the role of preoperative coronary angioplasty in this setting. The objective of this study was to determine the perioperative cardiac outcome in patients undergoing coronary angioplasty within six weeks of major noncardiac surgery. We analyzed our experience with 108 consecutive patients (85 males) with a mean age of 68 years (range 41-83) who underwent coronary angioplasty within 42 days of a major operative procedure, which was defined as either a vascular, thoracic or upper abdominal procedure. Multivessel disease was present in 48% of patients. Angioplasty success rate was 97% with 33 (31%) patients having more than one lesion dilated. Angioplasty complications included 1 stroke and 4 non-Q wave myocardial infarctions. The mean time from angioplasty to operative procedure was 14.5 days (range 0-41 days). Ninety six (91%) of the patients underwent vascular surgery--including 42 abdominal aneurysm repairs, 29 carotid endarterectomies, 21 lower extremity bypass operations and four renal artery bypass procedures. Eight patients had major abdominal surgery and one patient had a thoracic procedure. Postoperative cardiac complications included three non-Q wave myocardial infarctions and one Q-wave myocardial infarction which resulted in the only cardiac death (0.9%). There were no sustained ventricular arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of short-term outcomes following coronary artery stenting in men versus women.

This study sought to determine whether women have more adverse in-hospital outcomes after percutaneous transluminal coronary angioplasty (PTCA) and stenting compared with men. There is still controversy regarding whether female gender is an independent predictor of mortality after PTCA. No study has examined gender differences in outcomes following the dissemination of stenting. Data were obtained from the Nationwide Inpatient Sample. In 1997, there were 118,548 angioplasties (36% occurred in women and 59% involved placement of stents). Outcomes included same-admission mortality and coronary artery bypass grafting (CABG). Analyses were performed separately for patients with and without acute myocardial infarction (AMI). In 1997, women had a roughly twofold higher mortality than men in every comparison group, including conventional PTCA alone and stents. Mortality rates after stenting were 4.0% for women and 2.0% for men with AMI (p <0.0001), and 1.1% and 0.5%, respectively, for patients without AMI (p <0.0001). The adjusted odds ratios were 1.47 (95% confidence interval 1.23 to 1.75), and 1.65 (95% confidence interval 1.33 to 2.04), respectively. Similarly, following stenting, women had significantly higher CABG rates than men in both the AMI (1.6% vs 1.2%, p = 0.025) and no AMI groups (1.5% vs 1.0%, p <0.0001). After multivariate adjustment, the results retained significance in the no AMI setting, whereas there was a trend toward significance in the AMI group. This study demonstrates that, despite improved overall outcomes in patients who received stents, women who underwent stenting had higher rates of same-admission mortality and CABG compared with men. Furthermore, it confirms that female gender is an independent predictor of mortality after conventional PTCA.     

Coronary stenting versus balloon angioplasty in small coronary artery with complex lesions.

The impact of stenting on small vessels (< 3.0 mm) with complex lesions (B2-C) is still controversial. Restenosis rate in this population is high (> 40%). We compared early and late outcome of patients with complex coronary lesions in small vessel treated with traditional coronary angioplasty (angioplasty group) and with elective stent implantation (stent group). Angioplasty group (n = 97) and stent group (n = 112) were comparable for all clinical and angiographic characteristics. All patients in the two groups had clinical and angiographic follow-up. Major adverse cardiac events (MACE) and restenosis rate were evaluated. No patients in the two groups experienced in-hospital death or bypass surgery. Myocardial infarction occurred in four patients in the angioplasty group and in seven patients in the stent group (P = 0.36). No patients in either the angioplasty or the stent group had acute stent thrombosis, whereas subacute stent thrombosis occurred in only one patients of the stent group (0.9%). Long-term MACEs (20 +/- 4 month) were not different in the two groups (angioplasty group 39% vs. stent group 44%, P = 0.35). Target lesion revascularization rate was 33% in the angioplasty group and 34% in the stent group (P = 0.50). Restenosis rate was not statistically different in the two groups (stent group 41% vs. angioplasty group 38%, P = 0.41). In conclusion, compared to balloon angioplasty, elective stent implantation in small vessels with complex lesions does not improve early and late outcome. Cathet. Cardiovasc. Intervent. 50:390-397, 2000.     

Simultaneous dual coronary very late stent thrombosis following noncardiac surgery

Challenges arise in the care of patients with drug-eluting stents (DES) undergoing noncardiac surgery. The risk of bleeding during surgery must be balanced with the risk of stent thrombosis from interrupted dual antiplatelet therapy. We report a case of a patient with simultaneous stent thrombosis in two coronary arteries following discontinuation of clopidogrel for an elective noncardiac surgery 3 years after DES placement.     

Comparison of frequency of insulin resistance after coronary stenting in patients with type 2 diabetes mellitus with versus without coronary restenosis

The large incidence of restenosis after coronary angioplasty in diabetic patients renders this procedure less effective than in nondiabetics, and insulin resistance could be a relevant cause of restenosis in such patients. This study assessed insulin resistance and biologic markers of metabolic control in type 2 diabetic patients treated with stented angioplasty. Seventy-four patients were studied prospectively. Biochemical determinations, insulin tolerance test results, and the rate constant for plasma glucose disappearance (K(itt)%) were obtained. The angiographic outcome of angioplasty was assessed by quantitative coronary analysis at baseline and at 6 months in 64 patients (86%). Patients with restenosis had smaller minimum luminal diameters after stenting (2.8 +/- 0.5 vs 3.04 +/- 0.5 mm, p = 0.05), were more often hypertensive (97% vs 79%, p = 0.02) and treated with angiotensin-converting enzyme inhibitors (53% vs 23%, p = 0.02), and had smaller K(itt)% (2.9 +/- 1.6%/min vs 3.7 +/- 1.4%/min, p = 0.04) and larger titers of growth hormone (1.36 +/- 1.5 vs 0.68 +/- 0.6 ng/ml, p = 0.02).     

直接支架植入术与传统支架植入术治疗冠心病的对比研究

目的探讨直接支架植入术治疗冠心病患者的安全性、成功率和治疗效果。方法经冠状动脉造影,诊断明确,病变特征符合A型和B1型病变的冠心病患者165例,随机分为传统支架植入组(传统组)82例和直接支架植入组(直接组)83例,比较两组间手术成功率及并发症,心绞痛缓解率;支架置入时间;X线照射时间及造影剂用量。结果两组患者支架植入成功率及术后心绞痛缓解率均为100%;传统组与直接组并发症发生率均为2.4%。支架置入时间直接组(14.3±7.6)min,传统组(20.5±5.3)min,差异有统计学意义(P<0.05);X线照射时间直接组(4.9±3.5)min,传统组(7.6±2.9)min,差异有统计学意义(P<0.05);造影剂用量直接组(90±39)ml,传统组为(102±46)ml,差异有统计学意义(P<0.01)。结论直接支架植入术安全性、成功率和治疗效果与传统支架植入术一致,而且在支架植入时间、X线照射时间和造影剂用量明显低于传统支架植入术,值得临床推广应用。     

Sidebranch occlusion after coronary stenting with or without balloon predilation: direct versus conventional stenting

Direct stenting (DS) is a novel approach in percutaneous treatment of coronary artery lesions. Several studies confirmed the safety and feasibility of the procedure with success rates greater than 90%. However, the data regarding the incidence of sidebranch occlusion (SBO) after DS are scarce. The purpose of this study was to evaluate SBO (> 1 mm) after DS and compare it to conventional stenting (CS) with balloon predilation. The study population consisted of 151 patients (88 underwent DS, 63 underwent CS) with 185 sidebranches jailed by the stent (110 in DS group, 75 in CS group). SBO was observed in 20 out of 110 patients in the DS group (18.2%) and 18 out of 75 patients in the CS group (24%). Although the incidence of SBO was higher in the CS group compared to the DS group (24% vs. 18.2%, respectively), these values did not reach statistical significance (p > 0.05). Most of the SBOs were observed in cases with type D sidebranch morphology (p < 0.001) and in cases with sidebranch ostial diameter stenosis 50% (p = 0.019). None of the other clinical and angiographic variables predicted the SBO. To the best of our knowledge, this is the first report comparing incidence of SBO between two different PCI methods (CS vs DS). Randomized studies with larger patient populations should be conducted to compare this approach with conventional stenting.     

Comparison of coronary stenting versus conventional balloon angioplasty on five-year mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Little is known about the influence of stenting versus balloon angioplasty on long-term outcomes (particularly mortality) after primary percutaneous coronary intervention (PCI). We evaluated 2,087 patients with ST-elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction (PAMI) trials in the United States, who underwent primary PCI. The main outcome was all-cause mortality at 5 years, obtained through the National Death Index. Of the 2,087 patients, stenting was performed in 692 (33%). The absolute difference in the hospital (2.2% vs 3.3%), 1-year (3.3% vs 5.2%), and 5-year (10% vs 13%) mortality rates favored patients receiving a stent versus conventional balloon therapy, with the difference increasing with time. A multivariate Cox model identified stent use (vs balloon alone) as an independent correlate of lower 5-year mortality (hazard ratio 0.60, 95% confidence interval 0.42 to 0.85). The absolute reduction in mortality was greatest in the highest risk group. In conclusion, compared with balloon angioplasty, stenting during primary PCI not only resulted in better angiographic and short-term outcomes, but also in a sustained beneficial effect on mortality at 5 years. These data support the routine use of coronary stenting in most patients undergoing primary PCI, when feasible.     

Comparison of coronary artery bypass surgery and percutaneous transluminal coronary angioplasty including surgery for failed angioplasty

Selection and treatment of patients with ischemic heart disease is presently undergoing an evolutionary trend. Percutaneous transluminal coronary angioplasty (PTCA) has been recommended as the initial procedure for many patients with coronary artery disease and has thus redefined candidates for coronary artery bypass surgery. During our first years of experience with percutaneous angioplasty, 339 patients underwent the procedure and were compared with 338 patients who underwent isolated coronary artery bypass surgery. Patients who underwent PTCA had a shorter duration of angina and a lower number of prior myocardial infarctions and were found to have better left ventricular function (p less than 0.01). PTCA was considered initially successful in 87% (295 of 339) of patients. The most common finding at operation in those with failed angioplasty who underwent urgent or emergency revascularization was dissection of atheromatous plaque. Although the cumulative frequency of new Q waves in the entire 18-month angioplasty series was low (2.7%), the incidence was high (18%) in those with angioplasty failure and subsequent operation (N = 20) and significantly greater than in patients who had elective coronary artery bypass surgery (3.6%). Use of inotropic agents and lidocaine for ventricular arrhythmias was significantly higher in patients with unsuccessful PTCA who required operation than in those who underwent elective bypass surgery (10% vs 3% and 10% vs 1.5%, respectively; p less than 0.01). In an analysis of our entire experience between October 1980 and June 1982, 777 patients who had PTCA and 2068 patients who underwent coronary artery bypass surgery were analyzed for differences in clinical complications and early outcome.(ABSTRACT TRUNCATED AT 250 WORDS)