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An MI, a Stent, Bleeding, and Surgery!
What Do I Do?
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Patient
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Patient
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Cardiac cath post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
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PTCA post NSTEMI 5 months ago
*Reproduced with permission from Howard Weitz, MD
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Clear for Surgery?
Our Concerns:

Perioperative Risk

Antiplatelet management in the perioperative
period
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How to Determine Risk of MACE
 Low risk (<1%)
 Increased risk ( > 1%)
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211,410 + 257,385 = 468,795 patients
*Gupta PK et al. Development and Validation of a Risk Calculator for Prediction of Cardiac Risk After Surgery.
Circulation. 2011;124:381-387, published online before print July 5 2011, doi:10.1161/CIRCULATIONAHA.110.015701
Patient
 Age: 85
 Cr: > 1.5
 ASA Class: III (severe systemic disease)
 Functional: Independent
 Surgery: Intestinal
 Risk probability for perioperative MI or cardiac
arrest: 2.3%
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Risk predictors
4315 + 1422 = 5737 patients
High risk OR
Hx CAD
Hx CHF
Cerebrovasc dx
Diabetic insulin
Cr > 2
*Lee TH. et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery.
Circulation. 1999;100:1043-1049, doi:10.1161/01.CIR.100.10.1043
Revised Cardiac Index
 High risk surgery: intraperitoneal
 CAD: prior MI
 CHF: No
 Cerebrovascular disease: No
 Diabetes on insulin: Yes
 Serum creatinine > 2mg/dl: Yes
 Risk of MI, pulmonary edema, ventricular
fibrillation, cardiac arrest, complete heart block:
> 11%
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Perioperative Risk
 Risk of major cardiac event or death: 2.3 - > 11%
 Risk of not performing the surgery:



Continued GI bleed
Cancer growth
Bowel obstruction
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Stent
 Bleeding risk vs stent thrombosis
 Second generation DES since 2008

Less stent thrombosis
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ACC AHA 2014 Guideline
Delay elective surgery after stent
 Balloon angioplasty without stent: 14 days
 Bare metal stent: 30 days
 Drug eluting stent: 365 days
 Drug eluting stent: 180 days

If risk of delaying surgery is greater than the risk of stent
thrombosis – myocardial ischemia consider NCS after
180 days
*Fleisher LA, Fleischmann KE, Auerbach AD, 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(22):e77-e137.
doi:10.1016/j.jacc.2014.07.944.
European Society of Cardiology 2014 Guideline
Delay elective surgery after stent
 Bare metal stent: 4 week minimum, 3 months ideal
 Drug eluting stent (new generation): 6 months
A
minimum of 3 months might be acceptable
*The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC)
and the European Association for Cardio-Thoracic Surgery (EACTS). 2014 ESC/EACTS
Guidelines on myocardial Revascularization. European Heart Journal (2014) 35, 2541–2619.
NCS during the 2 years following stent
Risk of MI or need for coronary revascularization
 VA retrospective – older men
 Stents placed 2000 - 2010
 Risk highest (3.5%) immediately after stent
 Risk stabilizes (1.0%) at 6 months post stent
 Especially true for drug eluting stent
*Holcomb CN, Graham LA, Richman JS, et al. The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following
Coronary Stenting. J Am Coll Cardiol. 2014;64(25):2730-2739. doi:10.1016/j.jacc.2014.09.072.
Perioperative Cardiovascular Risk
 NSQIP database
 Mayo Clinic
 1120 patients with stents then NCS
2006 to 2011
 Risk of major adverse cardiac event and bleeding elevated
for 1 year post stent

*Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative Cardiovascular Risk of Prior Coronary Stent Implantation
Among Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2016;67(9):1038-1049.
doi:10.1016/j.jacc.2015.11.063.
Time to stent thrombosis
Stop ASA, stop
thienopyridine
Median 7 days
Continue ASA, stop
thienopyridine
Median 122 days (6% within
10 d)
*Eisenberg MJ et al. Safety of Short-Term Discontinuation of Antiplatelet Therapy in Patients With Drug-Eluting Stents.
Circulation. 2009; 119: 1634-1642 .
85-year-old man
right colectomy
 Continue aspirin
 Discontinue clopidogrel 5 days preop
 Resume clopidogrel asap postop
 Loading dose 300mg
 Heightened surveillance for postop stent
thrombosis
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85-year-old man
right colectomy
 Don’t forget other agents to decrease risk
 Statin
 Continue
beta blocker
 His anemia at time of NSTEMI should have raised
concern about drug eluting stent committing him to
long term asa + clopidogrel
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