Etiology
Noncardiac surgery ≤ 2 y after coronary stent placement was linked to perioperative MI and all-cause mortality Clinical impact rating:
Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64:2730-9.
多多多多多夞夞
Question
Conclusion
In patients who had coronary stent implantation, is subsequent noncardiac surgery associated with increased risk for perioperative adverse cardiac events?
Noncardiac surgery ≤ 2 years after coronary stent placement was linked to myocardial infarction and all-cause mortality.
Methods
*Hawn MT, Graham LA, Richman JS, et al. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462-72.
Design: Retrospective cohort study using data from national Veterans Affairs (VA) and Medicaid and Medicare databases, with 30-day follow-up after noncardiac surgery and equivalent follow-up after stent placement in a cohort of matched, nonsurgical patients. Setting: USA.
Source of funding: Veterans Affairs Health Services Research and Development. For correspondence: Dr. Mary T. Hawn, University of Alabama, Birmingham, AL, USA. E-mail [email protected].
Patients: 20 590 patients (median age 63 y, 98% men) who had coronary stent implantation, identified by International Classification of Diseases codes, at a VA medical center between Oct 1999 and Sep 2009, and noncardiac surgery, identified by Current Procedural Terminology codes, ≤ 2 years later (surgery cohort). Each patient in the surgery cohort was matched with 2 patients who did not have surgery ≤ 2 years after stent implantation and were alive at the time of surgery in the matched patient (n = 41 180). Matching was based on age, race, year of stent placement, stent type (bare metal [BMS] or drug-eluting [DES]), variables from the revised Cardiac Risk Index, and other previously identified predictors* of major adverse cardiac events, including myocardial infarction (MI) ≤ 6 mo before stent implantation and peripheral vascular disease. Patients who had surgery ≤ 2 weeks after coronary stent implantation were excluded.
Commentary
Risk factor: Noncardiac surgery ≤ 2 years after coronary stent implantation.
The study by Holcomb and colleagues has important clinical implications. It supports previous research showing that risk for perioperative complications was highest in the first 6 weeks after coronary stenting (2). It confirms that risk for adverse cardiac events remains elevated between 6 weeks and 6 months after stenting. The data also support 2014 European guidelines, which recommend delaying noncardiac surgery for at least 6 months after placement of second-generation DESs (3). Although patients with a BMS had higher rates of adverse cardiac events than those with a DES, Holcomb and colleagues provide a compelling rationale for a paradigm shift toward assessment of cardiac and surgical risk factors, rather than stent type, to determine timing of surgery after stent placement.
Outcomes: Primary outcome was a composite of cardiac events (acute MI or coronary revascularization using percutaneous coronary intervention or coronary artery bypass grafting). Other outcomes included all-cause mortality.
Main result Noncardiac surgery ≤ 2 years after coronary stent placement was linked to a composite of adverse cardiac events, MI, and all-cause mortality, but not revascularization (Table).
Association between noncardiac surgery ≤ 2 y after coronary stent placement and adverse cardiac events† Outcomes
Event rates
Future studies evaluating risk associated with noncardiac surgery should consider other nuanced factors, including number and type of stents used, stent implantation techniques, and alternative perioperative strategies when dual antiplatelet therapy is interrupted. Shashank S. Sinha, MD Kim A. Eagle, MD University of Michigan Ann Arbor, Michigan, USA
At 30 d‡
Noncardiac surgery
No surgery
RR (95% CI)
Adverse cardiac events§
3.1%
1.9%
1.67 (1.50 to 1.85)
Myocardial infarction
2.5%
1.1%
2.27 (2.00 to 2.56)
Revascularization
1.1%
1.0%
1.08 (0.92 to 1.27)
All-cause mortality
1.4%
0.4%
3.70 (3.05 to 4.48)
†Abbreviations defined in Glossary. Patients who had noncardiac surgery were matched with patients who did not have surgery based on age; race; year of stent placement; stent type; revised Cardiac Risk Index variables; and other predictors of major adverse cardiac events, including myocardial infarction ≤ 6 mo before stent implantation and peripheral vascular disease. ‡At 30 d after noncardiac surgery or corresponding time after stent placement in matched nonsurgery patients. §Acute myocardial infarction or coronary revascularization.
16 Jun 2015
The landscape of perioperative risk stratification has evolved, as about 1 in 5 patients needs noncardiac surgery within 2 years of coronary stent implantation (1). The retrospective cohort study by Holcomb and colleagues informs our understanding of the relative contributions of cardiac and surgical factors to perioperative adverse cardiac events. Patients who had noncardiac surgery within 2 years after coronary stent placement had greater risk for adverse cardiac events than matched patients who did not have surgery; incremental risk with surgery was highest, at 3.5%, immediately after stenting and stabilized at 0.9% ≥ 6 months after stenting. Further, elective inpatient procedures, use of DESs, and patients at high risk were each associated with significant reductions in incremental risk when noncardiac surgery was done ≥ 6 months after stenting compared with earlier. Study limitations include a mostly older male cohort and potential for misclassification bias due to the use of administrative data.
Annals of Internal Medicine
References 1. Gandhi NK, Abdel-Karim AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv. 2011;77:972-6. 2. Alshawabkeh LI, Banerjee S, Brilakis ES. Systematic review of the frequency and outcomes of non-cardiac surgery after drug-eluting stent implantation. Hellenic J Cardiol. 2011;52:141-8. 3. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA guidelines on noncardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35:2383-431.
ACP Journal Club
JC11
姝 2015 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/934140/ by a Imperial College London User on 07/24/2017
Noncardiac surgery ≤ 2 y after coronary stent placement was linked to perioperative MI and all-cause mortality Clinical impact rating:
Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64:2730-9.
多多多多多夞夞
Question
Conclusion
In patients who had coronary stent implantation, is subsequent noncardiac surgery associated with increased risk for perioperative adverse cardiac events?
Noncardiac surgery ≤ 2 years after coronary stent placement was linked to myocardial infarction and all-cause mortality.
Methods
*Hawn MT, Graham LA, Richman JS, et al. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462-72.
Design: Retrospective cohort study using data from national Veterans Affairs (VA) and Medicaid and Medicare databases, with 30-day follow-up after noncardiac surgery and equivalent follow-up after stent placement in a cohort of matched, nonsurgical patients. Setting: USA.
Source of funding: Veterans Affairs Health Services Research and Development. For correspondence: Dr. Mary T. Hawn, University of Alabama, Birmingham, AL, USA. E-mail [email protected].
Patients: 20 590 patients (median age 63 y, 98% men) who had coronary stent implantation, identified by International Classification of Diseases codes, at a VA medical center between Oct 1999 and Sep 2009, and noncardiac surgery, identified by Current Procedural Terminology codes, ≤ 2 years later (surgery cohort). Each patient in the surgery cohort was matched with 2 patients who did not have surgery ≤ 2 years after stent implantation and were alive at the time of surgery in the matched patient (n = 41 180). Matching was based on age, race, year of stent placement, stent type (bare metal [BMS] or drug-eluting [DES]), variables from the revised Cardiac Risk Index, and other previously identified predictors* of major adverse cardiac events, including myocardial infarction (MI) ≤ 6 mo before stent implantation and peripheral vascular disease. Patients who had surgery ≤ 2 weeks after coronary stent implantation were excluded.
Commentary
Risk factor: Noncardiac surgery ≤ 2 years after coronary stent implantation.
The study by Holcomb and colleagues has important clinical implications. It supports previous research showing that risk for perioperative complications was highest in the first 6 weeks after coronary stenting (2). It confirms that risk for adverse cardiac events remains elevated between 6 weeks and 6 months after stenting. The data also support 2014 European guidelines, which recommend delaying noncardiac surgery for at least 6 months after placement of second-generation DESs (3). Although patients with a BMS had higher rates of adverse cardiac events than those with a DES, Holcomb and colleagues provide a compelling rationale for a paradigm shift toward assessment of cardiac and surgical risk factors, rather than stent type, to determine timing of surgery after stent placement.
Outcomes: Primary outcome was a composite of cardiac events (acute MI or coronary revascularization using percutaneous coronary intervention or coronary artery bypass grafting). Other outcomes included all-cause mortality.
Main result Noncardiac surgery ≤ 2 years after coronary stent placement was linked to a composite of adverse cardiac events, MI, and all-cause mortality, but not revascularization (Table).
Association between noncardiac surgery ≤ 2 y after coronary stent placement and adverse cardiac events† Outcomes
Event rates
Future studies evaluating risk associated with noncardiac surgery should consider other nuanced factors, including number and type of stents used, stent implantation techniques, and alternative perioperative strategies when dual antiplatelet therapy is interrupted. Shashank S. Sinha, MD Kim A. Eagle, MD University of Michigan Ann Arbor, Michigan, USA
At 30 d‡
Noncardiac surgery
No surgery
RR (95% CI)
Adverse cardiac events§
3.1%
1.9%
1.67 (1.50 to 1.85)
Myocardial infarction
2.5%
1.1%
2.27 (2.00 to 2.56)
Revascularization
1.1%
1.0%
1.08 (0.92 to 1.27)
All-cause mortality
1.4%
0.4%
3.70 (3.05 to 4.48)
†Abbreviations defined in Glossary. Patients who had noncardiac surgery were matched with patients who did not have surgery based on age; race; year of stent placement; stent type; revised Cardiac Risk Index variables; and other predictors of major adverse cardiac events, including myocardial infarction ≤ 6 mo before stent implantation and peripheral vascular disease. ‡At 30 d after noncardiac surgery or corresponding time after stent placement in matched nonsurgery patients. §Acute myocardial infarction or coronary revascularization.
16 Jun 2015
The landscape of perioperative risk stratification has evolved, as about 1 in 5 patients needs noncardiac surgery within 2 years of coronary stent implantation (1). The retrospective cohort study by Holcomb and colleagues informs our understanding of the relative contributions of cardiac and surgical factors to perioperative adverse cardiac events. Patients who had noncardiac surgery within 2 years after coronary stent placement had greater risk for adverse cardiac events than matched patients who did not have surgery; incremental risk with surgery was highest, at 3.5%, immediately after stenting and stabilized at 0.9% ≥ 6 months after stenting. Further, elective inpatient procedures, use of DESs, and patients at high risk were each associated with significant reductions in incremental risk when noncardiac surgery was done ≥ 6 months after stenting compared with earlier. Study limitations include a mostly older male cohort and potential for misclassification bias due to the use of administrative data.
Annals of Internal Medicine
References 1. Gandhi NK, Abdel-Karim AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv. 2011;77:972-6. 2. Alshawabkeh LI, Banerjee S, Brilakis ES. Systematic review of the frequency and outcomes of non-cardiac surgery after drug-eluting stent implantation. Hellenic J Cardiol. 2011;52:141-8. 3. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA guidelines on noncardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35:2383-431.
ACP Journal Club
JC11
姝 2015 American College of Physicians
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/934140/ by a Imperial College London User on 07/24/2017
