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An MI, a Stent, Bleeding, and Surgery!
What Do I Do?
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Patient
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Patient
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Cardiac cath post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
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PTCA post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
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Clear for Surgery?
Our Concerns:
Perioperative Risk
Antiplatelet management in the perioperative
period
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How to Determine Risk of MACE
Low risk (<1%)
Increased risk ( > 1%)
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211,410 + 257,385 = 468,795 patients
*Gupta PK et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery.
Circulation. 2011;124:381-387, published online before print July 5 2011, doi:10.1161/CIRCULATIONAHA.110.015701
Patient
Age: 85
Cr: > 1.5
ASA Class: III (severe systemic disease)
Functional: Independent
Surgery: Intestinal
Risk probability for perioperative MI or cardiac
arrest: 2.3%
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Risk predictors
4315 + 1422 = 5737 patients
High risk OR
Hx CAD
Hx CHF
Cerebrovasc dx
Diabetic insulin
Cr > 2
*Lee TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery.
Circulation. 1999;100:1043-1049, doi:10.1161/01.CIR.100.10.1043
Revised Cardiac Index
High risk surgery: intraperitoneal
CAD: prior MI
CHF: No
Cerebrovascular disease: No
Diabetes on insulin: Yes
Serum creatinine > 2mg/dl: Yes
Risk of MI, pulmonary edema, ventricular
fibrillation, cardiac arrest, complete heart block:
> 11%
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Perioperative Risk
Risk of major cardiac event or death: 2.3 - > 11%
Risk of not performing the surgery:
Continued GI bleed
Cancer growth
Bowel obstruction
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Stent
Bleeding risk vs stent thrombosis
Second generation DES since 2008
Less stent thrombosis
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ACC AHA 2014 Guideline
Delay elective surgery after stent
Balloon angioplasty without stent: 14 days
Bare metal stent: 30 days
Drug eluting stent: 365 days
Drug eluting stent: 180 days
If risk of delaying surgery is greater than the risk of stent
thrombosis – myocardial ischemia consider NCS after
180 days
*Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation
and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137.
doi:10.1016/j.jacc.2014.07.944.
European Society of Cardiology 2014 Guideline
Delay elective surgery after stent
Bare metal stent: 4 week minimum, 3 months ideal
Drug eluting stent (new generation): 6 months
A
minimum of 3 months might be acceptable
*The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC)
and the European Association for Cardio-Thoracic Surgery (EACTS). 2014 ESC/EACTS
Guidelines on myocardial Revascularization. European Heart Journal (2014) 35, 2541–2619.
NCS during the 2 years following stent
Risk of MI or need for coronary revascularization
VA retrospective – older men
Stents placed 2000 - 2010
Risk highest (3.5%) immediately after stent
Risk stabilizes (1.0%) at 6 months post stent
Especially true for drug eluting stent
*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(25):2730-2739. doi:10.1016/j.jacc.2014.09.072.
Perioperative Cardiovascular Risk
NSQIP database
Mayo Clinic
1120 patients with stents then NCS
2006 to 2011
Risk of major adverse cardiac event and bleeding elevated
for 1 year post stent
*Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation
Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2016;67(9):1038-1049.
doi:10.1016/j.jacc.2015.11.063.
Time to stent thrombosis
Stop ASA, stop
thienopyridine
Median 7 days
Continue ASA, stop
thienopyridine
Median 122 days (6% within
10 d)
*Eisenberg MJ et al. Safety of Short-Term Discontinuation of Antiplatelet Therapy in Patients With Drug-Eluting Stents.
Circulation. 2009; 119: 1634-1642 .
85-year-old man
right colectomy
Continue aspirin
Discontinue clopidogrel 5 days preop
Resume clopidogrel asap postop
Loading dose 300mg
Heightened surveillance for postop stent
thrombosis
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85-year-old man
right colectomy
Don’t forget other agents to decrease risk
Statin
Continue
beta blocker
His anemia at time of NSTEMI should have raised
concern about drug eluting stent committing him to
long term asa + clopidogrel
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