CARDIAC STENTS AND PERIOPERATIVE MANAGEMENT
Preoperative evaluation
Patients with pre-existing cardiac stents:
- Information to obtain:
What type? |
Bare metal, drug eluting |
When was it placed? |
In general, all patients should receive 1 year of aspirin plus clopidogrel after stent placement |
Why was it placed |
MI or angina? |
How urgent is the surgery? |
Weigh risk of coming off antiplatelet therapy |
Is the patient having symptoms? |
May prompt cardiology evaluation |
- AHA/ACC guidelines1:
Stent |
Aspirin (once daily) |
Clopidogrel (once daily) |
Bare metal |
162-325 mg at least 1 month, then |
75 mg for at least 1 month |
Sirolimus |
162-325 mg at least 3 months, then |
75 mg daily at least 12 months |
Paclitaxel |
162-325 mg at least 6 months, then |
75 mg daily at least 12 months |
- Review antiplatelet agent plan with patient’s cardiologist—in some high-risk cases, dual antiplatelet therapy is extended beyond 12 months.
- No elective procedures should be done during the first year following stent placement unless they can be done without stopping aspirin and clopidogrel.
Potential strategies:
Type of surgery |
Example |
Strategy |
Purely elective |
Total knee replacement |
Postpone surgery for one year post stent placement, especially for drug-eluting stents. Reassess patient at that time. |
Urgent, low bleeding risk |
Minor ENT procedure for cancer |
Determine if the operation can be done without stopping aspirin and/or clopidogrel. |
Urgent, high bleeding risk |
Obstructing colon cancer |
Withhold antiplatelet agents in the narrowest time frame acceptable with regard to surgical bleeding risk. Aggressively manage heart rate, blood pressure, and other risk factors. |
In all cases, re-start antiplatelet therapy as soon as possible post-procedure.
Discussion with the patient, the patient’s cardiologist, and the surgical team is essential. In some cases the procedure may be performed with continuation of aspirin.
Preoperative stents placed to reduce cardiovascular risk:
Generally not recommended—by placing a stent and subsequently withholding dual antiplatelet therapy for a procedure, additional risk is introduced (risk of acute in-stent thrombosis) because of the presence of the stent.
For patients with a positive stress test and/or active symptoms of ischemic heart disease for whom you are considering revascularization, please see section on “What to do with a positive stress test”.
Postoperative management
- Restart antiplatelet therapy as soon as possible.
- Follow closely for symptoms or signs of cardiac ischemia.
Discussion
Drug eluting stents (DES) such as sirolimus and paclitaxel decrease revascularization and restenosis rates compared with bare metal stents. However, there is no difference in mortality or MI. (Ref 2)
In-stent thrombosis represents an acute event, unlike restenosis. In clinical trials, there was no significant difference between DES and BMS, although the incidence was rare (0.5 to 0.7%) and therefore underpowered. (Ref 2) “Real-world” cohorts of patients with drug-eluting stents have a higher incidence (1.3%), and suggest that discontinuation of antiplatelet therapy is a risk factor (hazard ratio = 90) for thrombosis. (Ref 3) When it does occur, outcomes are serious: Case fatality rate is 45% for in-stent thrombosis of drug eluting stents.(Ref 3)
References
- 1. King SB, Smith SC, Hirshfeld JW, et al. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. Circulation. 2008; 117:261-295. (AHA/ACC guidelines update)
- 2. Babapulle MN, Joseph L, Belisle P, et al. A Hierarchical Bayesian Meta-Analysis of Randomised Clinical Trials of Drug-Eluting Stents. Lancet. 2004;364:583-591.
- 3. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, Predictors, and Outcome of Thrombosis after Successful Implantation of Drug-Eluting Stents. JAMA. 2005; 293:2126-2130.
Updated May 2011