Thromb Haemost 2016; 116(01): 172-180
DOI: 10.1160/TH15-12-0954
Atherosclerosis and Ischaemic Disease
Schattauer GmbH

Dual anti-platelet therapy after coronary drug-eluting stent implantation and surgery-associated major adverse events

Gro Egholm
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
2   Department of Clinical Epidemiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Troels Thim
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Kevin Kris Olesen
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Morten Madsen
2   Department of Clinical Epidemiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Henrik Toft Sorensen
2   Department of Clinical Epidemiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Svend Eggert Jensen
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Lisette Okkels Jensen
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Hans Erik Botker
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Steen Dalby Kristensen
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
,
Michael Maeng
1   Department of Cardiology, Aarhus Universitetshospital, Aarhus, Denmark
› Author Affiliations
Further Information

Publication History

Received: 14 December 2015

Accepted after major revision: 15 March 2016

Publication Date:
27 November 2017 (online)

Summary

Surgery may necessitate interruption of dual antiplatelet therapy (DAPT) within the first year after coronary drug-eluting stent (DES) implantation. We conducted a population-based cohort study to assess the rate of surgery within the first year after DES implantation, surgery-associated major adverse cardiac events (MACE), reoperation for bleeding within 30 days after surgery, and two nested case-control analyses to explore any association between preoperative antiplatelet therapy, MACE, and reoperation for bleeding. In the cohort of 22,654 patients treated with DES, 1,944 patients (8.6 %) underwent moderate- to high-risk surgery within 12 months. Of these, 62 (3.2 %) experienced MACE and 54 (2.8 %) needed reoperation for bleeding within 30 days. In the nested case-control analyses of 458 cases and controls, where 70 % (n=324) had a first generation DES, absence of preoperative antiplatelet therapy was associated with an increased MACE rate (OR 2.36, 95 % CI 1.02–5.48) compared to single antiplatelet therapy (SAPT) or DAPT. Preoperative SAPT versus DAPT showed no difference in MACE rates (OR 0.85, 95 % CI 0.30–2.40). Surgery within the first month was associated with increased MACE rate (OR 4.67, 95 % CI 2.22–9.83) compared to surgery 2–12 months after DES implantation. Absence of preoperative antiplatelet therapy did not reduce reoperation for bleeding as compared to patients on SAPT or DAPT (OR 1.32, 95 % CI 0.56–3.12). In conclusion, absence of preoperative antiplatelet therapy and surgery within the first month after DES implantation were associated with increased MACE rates.

 
  • References

  • 1 Authors/Task Force members. Windecker S. et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541-2619.
  • 2 Berger PB. et al. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv 2010; 03: 920-927.
  • 3 Alshawabkeh LI. et al. Systematic review of the frequency and outcomes of noncardiac surgery after drug-eluting stent implantation. Hellenic J Cardiol 2011; 52: 141-148.
  • 4 Cruden NL. et al. Previous coronary stent implantation and cardiac events in patients undergoing noncardiac surgery. Circ Cardiovasc Interv 2010; 03: 236-242.
  • 5 Hawn MT. et al. The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg 2012; 214: 658-666.
  • 6 Tokushige A. et al. Incidence and Outcome of Surgical Procedures After Coronary Bare-Metal and Drug-Eluting Stent Implantation: A Report From the CREDO-Kyoto PCI/CABG Registry Cohort-2. Circ Cardiovasc Interv 2012; 05: 237-246.
  • 7 Anwaruddin S. et al. Characterization of post-operative risk associated with prior drug-eluting stent use. JACC Cardiovasc Interv 2009; 02: 542-549.
  • 8 Chassot PG. et al. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007; 99: 316-328.
  • 9 To AC. et al. Noncardiac surgery and bleeding after percutaneous coronary intervention. Circ Cardiovasc Interv 2009; 02: 213-221.
  • 10 Kristensen SD. et al. 2014 ESC/ESA Guidelines on non-cardiac 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: 2383-2431.
  • 11 Fleisher LA. 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: e77-137.
  • 12 Schmidt M. et al. Existing data sources for clinical epidemiology: The Western Denmark Heart Registry. Clin Epidemiol 2010; 02: 137-144.
  • 13 Lynge E. et al. The Danish National Patient Register. Scand J Public Health 2011; 39 (07) 30-33.
  • 14 Pedersen CB. The Danish Civil Registration System. Scand J Public Health 2011; 39 (07) 22-25.
  • 15 Pedersen CB. et al. The Danish Civil Registration System. A cohort of eight million persons. Dan Med Bull 2006; 53: 441-449.
  • 16 Cutlip DE. et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115: 2344-2351.
  • 17 Helweg-Larsen K. The Danish Register of Causes of Death. Scand J Public Health 2011; 39 (07) 26-29.
  • 18 Kildemoes HW. et al. The Danish National Prescription Registry. Scand J Public Health 2011; 39 (07) 38-41.
  • 19 Thygesen SK. et al. The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients. BMC Med Res Methodol. 2011 11. 83-2288-11-83.
  • 20 Radovanovic D. et al. Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002-2012. Heart 2014; 100: 288-294.
  • 21 Hollis RH. et al. Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review. Am J Surg 2012; 204: 494-501.
  • 22 Hawn MT. et al. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. J Am Med Assoc 2013; 310: 1462-1472.
  • 23 Thim T. et al. Clopidogrel discontinuation within the first year after coronary drug-eluting stent implantation: an observational study. BMC Cardiovasc Disord. 2014 14. 100-2261-14-100
  • 24 Mehran R. et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet 2013; 382: 1714-1722.
  • 25 Rossini R. et al. Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery. Results of a multicentre registry. Thromb Haemost 2014; 113: 272-282.
  • 26 Eisenberg MJ. et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation 2009; 119: 1634-1642.
  • 27 Myles PS. et al. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med 2016; 374: 728-737.
  • 28 Marino M. et al. Cangrelor: review of the drug and the CHAMPION programme (including PHOENIX). Curr Cardiol Rep. 2014 16. 493-014-0493-4
  • 29 van Kuijk JP. et al. Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents. Am J Cardiol 2009; 104: 1229-1234.
  • 30 Urban P. et al. Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk. N Engl J Med 2015; 373: 2038-2047.