Monday, December 15, 2014

Non cardiac surgery after PCI

This is one of the most vexing perioperative issues for hospitalists and was the topic of a recent review article in the American Journal of Cardiology. Surgery post PCI is a difficult situation because it is the interface of two pro-thrombotic conditions, a local one (the recently manipulated artery which has not had time to endothelialize) and a systemic pro-thrombotic state resulting from the surgery.

The review offers a summary of current guidelines and more recent evidence along with a suggested approach. From the review, concerning the guidelines:

Current consensus multisociety guidelines suggest delaying elective surgery for greater than or equal to 1 year after DES implantation and for greater than or equal to 4 to 6 weeks after BMS implantation. If surgery is warranted before that period, it should be performed while on DAPT if safe. Minimums of 6 to 12 months and 4 to 6 weeks of DAPT, respectively, after DES and BMS implantation before NCS are recommended in national guidelines. If surgery is anticipated within 30 days of revascularization or if DAPT is not feasible, balloon angioplasty without stenting may be a reasonable strategy if NCS is anticipated. These recommendations are based largely on expert opinion in conjunction with limited and variable evidence based on first-generation DESs.

The authors note that newer generation drug eluging stents may be safer and thus allow earlier interruption of DAPT. In the suggested approach that follows, however, they emphasize that this remains unproven:

We propose the following simplified approach to such patients. (1) It is reasonable to postpone elective surgical procedures for greater than or equal to 6 weeks after BMS implantation and for greater than or equal to1 year after first-generation DES implantation. Second-generation DESs have a more favorable thrombogenicity profile, and emerging data suggest that it may be safe to discontinue DAPT as early as 3 months after stent implantation. Consequently, it may be feasible to safely perform NCS 3 to 6 months after second-generation DES implantation, but this remains unproved. (2) Urgent or unplanned surgery should be performed on DAPT if feasible, but this is the exception.

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