Stent type may not be related to adverse cardiac events after surgery

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1. The major predictors of major adverse cardiac events in non-cardiac surgery in the two years following cardiac stent placement were severity of underlying cardiac disease, emergent need for surgery, and surgery within six months of stent placement according to this retrospective cohort study. 

2. This study did not find any significant difference in the risk of major adverse cardiac events between bare metal stents and drug eluting stents and length of time since stent placement after six months. 

3. No association between major adverse cardiac events and cessation of antiplatelet therapy peri-operatively was found in a smaller nested case-control study. 

Evidence Rating Level:  2 (Good)          

Study Rundown: Percutaneous cardiac stent placement has been associated with an increased risk of cardiac adverse events after non-cardiac surgery.  The difference in risk between drug eluting stents and bare metal stents is an area of controversy.  While there are clear guidelines regarding non-cardiac surgery after stent placement, many of the recommendations are not based on strong data.  This retrospective cohort study followed patients after 41,989 non-cardiac operations occurring within 24 months of cardiac stent placement for major adverse cardiac events within 30 days of surgery.  Major adverse cardiac events were defined as death from any cause, myocardial infarction, or need for coronary revascularization. Ultimately, the factors that were associated with adverse cardiac events were acuity of presentation for surgery and severity of underlying cardiac disease. Also, it was found that the time from surgery was associated with adverse cardiac events, but mainly in the first six months.  Notably, there was no significant difference in risk of adverse cardiac events between patients with bare metal stents and drug eluting stents. A nested case-control study was performed to assess the risk of major adverse cardiac events with peri-operative cessation of antiplatelet therapy and did not find an increase in risk.  An important strength of the study is the large sample size.  One significant weakness of this study is the fact that the population was mainly older males, and these findings may not be generalizable to females or a younger population.  Prospective research studies including a more heterogeneous population will be required before recommendations about surgery after cardiac stent placement can be changed.

Click to read the study published today in JAMA

Relevant Reading: Outcomes Following Coronary Stenting in the Era of Bare-Metal vs. the Era of Drug-Eluting Stents

In-Depth [retrospective cohort]: This study included a total of 41,989 surgeries and measured major adverse cardiac events (death, myocardial infarction, and need for revascularization) in the first 30 days post-operatively. The overall rate of major adverse cardiac events was 4.7% (95% CI, 4.5%-4.9%).  Individuals undergoing elective surgery were less likely than those undergoing emergent surgery to have major adverse cardiac events (p<0.001).  Also, cardiac risk index was correlated with increased risk of major adverse cardiac effects (p<0.001).  Before the 6-month mark, there was an increased risk of adverse cardiac events, but a stabilization of risk after 6 months.  Finally, there was no greater risk of major adverse cardiac events with drug eluting stents than bare metal stents (OR 0.91, 95% CI 0.83-1.01, p=0.08).  A nested-case control study was performed in order to assess risk of major adverse cardiac events with cessation of antiplatelet therapy in the peri-operative period.  This analysis found that there was no association between antiplatelet therapy cessation and major adverse cardiac effects (OR 0.86, 95% CI 0.57-1.29).

By Jeffrey Cohen and Brittany Hasty

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