Between a rock and a hard place: commentary on "adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review".

In the accompanying article “Adverse Cardiac Events in Patients with Coronary Stents Undergoing Noncardiac Surgery: A Systematic Review,” Dr. Hawn’s group from the University of Alabama has addressed one of the more perplexing issues facing surgeons today—managing the patient with a drug-eluting cardiac stent (DES). Current guidelines from the American Heart Association and the American College of Cardiology recommend delaying elective surgeries until 1 year of dual antiplatelet therapy has been completed. If surgery must be performed, continuing the dual antiplatelet therapy is recommended, which is a daunting proposal for the abdominal surgeon. Although there are only 2 studies that specifically examine the risk of surgical bleeding associated with clopidogrel, 1,2 they both show that its use less than 7 days before elective abdominal surgery led to a higher risk of bleeding requiring blood transfusion without increases in intensive care unit stay or mortality. Surgical urban legends of these experiences are far worse. Dr. Hawn’s group performed a systematic literature review of major adverse cardiac events (MACEs) associated with noncardiac surgery in patients with DES. Not surprisingly, only 28 of 358 (8%) studies met the inclusion criteria. Overall, MACE rates decreased as the time to surgery increased and varied from 0% to 18% for surgeries performed within 1 year compared with 0% to 12% for surgery more than 1 year after a stent. The literature showed limited evidence for a protective effect of continuing perioperative dual antiplatelet therapy on MACE rates. Although published data support a significant decrease in MACE when surgery is delayed for over 1 year, the level of evidence is weak (ie, level C evidence). Therefore, insufficient evidence, mostly from nonrandomized trials, recommends decreased MACE risks when dual antiplatelet therapy was continued in the perioperative period. The authors rightly conclude that the current recommendations to delay elective surgery after DES for 1 year are based on limited evidence and the balance between benefits and risks are too close for making general recommendations. Ultimately, practicing surgeons will probably still delay elective surgeries such as hernias and hysterectomies for a year and soldier on fearfully when surgeries must be performed more urgently in the face of dual antiplatelet therapy. The use of bare metal stents is an option that should be considered in patients whose likelihood for surgical intervention is less than a year because they endothelialize in approximately 3 months. Their usage should be considered by open communication between the primary physician, the surgeon, and the cardiologist. Newer data showing a divergence of outcomes favoring coronary artery bypass to DES may also influence behavior. 3 Can this information translate into clinical guidelines for the practicing surgeon? The answer is probably not because there is too much concern and control among cardiology circles and the ever-present specters of liability. A randomized prospective trial to explore this question most assuredly will never occur for the same reasons. However, can this excellent review reassure the surgeon and the patient? An emphatic yes is my answer, and I recommend sharing it with your surgical and cardiologic colleagues as well.