Six-month surgery delay ‘acceptable’ after DES implantation

By Lynda Williams, Senior medwireNews Reporter

The recommendation to delay noncardiac surgery for a year after receipt of a drug-eluting stent (DES), compared with just 6 weeks for a bare-metal stent (BMS), may be too conservative, suggests research indicating that stent type does not influence the longer term risk for major adverse cardiac events (MACE).

“The present findings suggest that underlying surgical and cardiac risk, rather than stent type, are the primary factors associated with perioperative MACE; that event rates stabilize by 6 months; and that APT [antiplatelet therapy] continuation does not substantially mitigate risk,” say Mary Hawn (University of Alabama at Birmingham, USA) and co-authors.

“Accordingly, the current focus of the guidelines on differential timing recommendations by stent type may warrant reconsideration, and greater concentration may need to be placed on assessing and optimizing cardiac risk.”

The combined endpoint of all-cause mortality, myocardial infarction (MI) or cardiac revascularization occurred in 4.7% of 28,029 patients who underwent noncardiac surgery within 2 years of stenting, the team reported concurrently in JAMA and at the American College of Surgeons 2013 Annual Clinical Congress.

The risk for MACE after noncardiac surgery significantly reduced with time from stenting, from 11.6% for patients treated within 6 weeks to 6.4% within 6 months, 4.2% within 6 to 12 months, and just 3.5% for 12 to 24 months.

In propensity analysis, however, the strongest predictors for MACE were nonelective surgery (adjusted odds ratio [AOR]=4.77 versus outpatient or elective surgery), MI in the 6 months before surgery (AOR=2.63), and a moderate risk score on the revised cardiac index (AOR=2.13).

Time between stenting and noncardiac surgery was only ranked fifth out of the 12 explanatory measures for MACE, the researchers report. And stent type was ranked last, with no significant difference in the risk for MACE after noncardiac surgery 6 months after stenting with DES and BMS.

Finally, assessment of 284 pairs of patients found that patients who stopped using APT were not at significantly higher risk for MACE after noncardiac surgery than those who continued treatment.

In an accompanying JAMA editorial, Emmanouil Brilakis and Subhash Banerjee, from the University of Texas Southwestern Medical Center at Dallas, USA, write: “For patients with DES, surgery performed at least 6 months after DES implantation appears to carry low risk for stent thrombosis, especially with contemporary, second-generation DES, which have more biocompatible, durable polymer coatings.

“Hence, nonurgent operations should be postponed until 6 months after stent implantation,” they recommend.

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