Preoperative Management of Patients with Coronary Artery Stents

Introduction

• Perioperative management of patients with coronary artery stents could be challenging, mainly when stents are placed within one year of the NCS, and there would be a requirement to hold one of the antiplatelet medications and interrupt the DAPT.
• The 2024 ACC AHA guidelines highlighted an evidence-based approach to the perioperative management of patients with coronary stents undergoing NCS.¹
• A team-based approach is recommended as the decision to proceed with NCS in a patient with coronary artery disease and a cardiac stent should involve the surgeon, the anesthesiologist, and the cardiologist, in addition to shared decision making with the patient and family, which is recommended (Class 1 recommendation)
  • The approach will include evaluating ischemic risk after cardiac stent placement and considering discontinuation of DAPT.
  • Input from cardiology will allow evaluation of unique coronary anatomy and complex PCI, such as bifurcation stents, long stent lengths, and multivessel PCI, or when the PCI details are unavailable. It will weigh in on the optimal timing to interrupt DAPT without increasing the risk of major adverse cardiac events (MACE).^1,2
  • Engaging the surgery team will allow discussion of the optimal timing for surgery after PCI, evaluating the benefits of proceeding with NCS against the risk of MACE.
  • Engaging the surgery team will also allow for an early discussion regarding the need to interrupt one or both antiplatelet medications versus no interruption at all.

Preoperative Management of Patients with Coronary Artery Stents

Timing of NCS After Percutaneous Coronary Intervention (PCI)

• Timing of interruption of DAPT should be balanced against the thrombotic risk of the stents and the bleeding risk of surgery.
• In patients with recent coronary balloon angioplasty without stent placement, elective noncardiac surgery should be delayed by a minimum of 14 days to minimize the risk of MACE (Class 1 recommendation).
• The risk of perioperative stent thrombosis is highest in the first 4 to 6 weeks after PCI, with elevated risks that decrease over time.
• For most patients with chronic coronary artery disease (CCD), DAPT is recommended for 6 months, followed by single antiplatelet therapy (either with aspirin or a P2Y12 inhibitor).
• Patients who had PCI after an ACS, i.e., acute myocardial infarction (MI), non-ST-elevation (NSTEMI), or STEMI, are at a 3-fold higher risk of postoperative MACE when compared to those who received PCI for CCD as an indication. 1,2 As a result, it is recommended to postpone NCS for at least one year after PCI for ACS and at least 6 months after PCI for chronic coronary disease.
• However, for time-sensitive NCS, a team-based approach to evaluate the risk of proceeding with NCS and interrupting DAPT versus the benefits of surgery is necessary and can allow surgery to proceed after 3 months of PCI.
• In patients who require time-sensitive surgery, balloon angioplasty without stents can be considered, and NCS can be delayed for a minimum of 14 days due to the increased risk of perioperative major adverse cardiac events early after PCI.

Management of Patients with a Coronary Stent for Time-Sensitive NCS

• In patients with recent PCI and a time-sensitive indication for surgery, such as oncological surgery, a risk assessment to balance the potential delay of surgery against the risk of MACE should be completed in a multidisciplinary approach (discussion among surgery, anesthesiology, and cardiology).
• The risk of MACE is highest when surgery is performed within the first 3 months after PCI. In a study comparing the incidence of MACE after PCI, the rate was 2.8% at 3 months versus 10.5% when surgery was performed within the first 30 days after PCI with a BMS. The incidence of perioperative MACE after NCS was also lowest if surgery was performed >3 months after PCI using a DES.^3,4
• In a large analysis of nonsurgical patients after PCI, DAPT discontinuation >3 months was not associated with an increased risk of stent thrombosis.⁵
• In selected patients, it may be reasonable to perform NCS at least 3 months after PCI if the benefits of the procedure outweigh the risk of MACE (Class 2b recommendation).

Proceeding with NCS Within 30 days After PCI

• It is recommended not to proceed with elective noncardiac surgery within the first 30 days after PCI due to increased risk of MACE (Class 3 recommendation = harm).
• Reported outcomes include postoperative MI, stent thrombosis, bleeding, and increased mortality.
• Pathophysiological explanation: Surgery-associated tissue trauma results in increased catecholamines, inflammatory cytokines, activation of the clotting cascade, increased platelet activation, and decreased fibrinolysis. These physiological consequences of surgery result in the increased risk of perioperative thrombosis and increased risk of MACE.
• Reported incidence of MACE after NCS within 30 days is: MI (7.2% versus 0.5%), cardiac death (5% versus 0.4%), and all-cause mortality (9% versus 2.1%) than those undergoing surgery within the first 12 months after PCI.⁶

Management of DAPT

• In patients with prior PCI undergoing noncardiac surgery, it is recommended to continue aspirin (75-100 mg) if possible, to minimize the risk of cardiac events (Class 1 recommendation).
  • Aspirin use was associated with lower rates of MI and death when compared to the risk of major bleeding.
  • When DAPT interruption is required, aspirin monotherapy should be continued when possible.
  • Table 1 summarizes the minimum time from drug interruption to restoration of platelet function of commonly used antiplatelet drugs.
• In patients with coronary artery disease who require time-sensitive NCS within 30 days of PCI with a bare metal stent or less than 3 Months of PCI with a DES, DAPT should be continued unless the risk of bleeding outweighs the benefit of the prevention of stent thrombosis (Class 1 recommendation).
  • Continuation of DAPT should be the result of a multidisciplinary discussion, including the surgery team, to weigh in on the risk of bleeding.
• In patients with prior PCI in whom oral anticoagulant monotherapy must be discontinued before NCS, aspirin should be substituted when feasible in the perioperative period until OAC can be safely reinitiated (Class 1 recommendation)
• In select patients after PCI who have a high thrombotic risk, perioperative bridging with intravenous antiplatelet therapy may be considered less than 6 months after a DES or <30 days after a bare metal stent if NCS cannot be deferred.
  • The BRIDGE trial (Bridging Antiplatelet Therapy With Cangrelor in Patients Undergoing Cardiac Surgery) assessed stopping oral P2Y12 inhibitors and switching to cangrelor versus placebo. This study involving patients having coronary artery bypass graft showed increased platelet inhibition with cangrelor without a high risk of major bleeding.7
  • The decision to proceed with bridging should be discussed in a multidisciplinary setting, involving cardiology and surgery, to provide recommendations for a select group of patients.
  • Current evidence does not support routine bridging, as it has not been shown to reduce perioperative cardiac events and may increase bleeding risk.
  • Bridging may be considered in very select, high-thrombotic-risk patients after careful multidisciplinary discussion.

Perioperative Management of Antiplatelet Therapy in Patients Without a Coronary Stent

• In patients with CCD without prior PCI undergoing elective NCS, it may be reasonable to continue Aspirin in selected patients when the risk of cardiac events outweighs the risk of bleeding (Class 2b recommendation).
  • In observational studies, aspirin continuation was associated with a 1.5-fold increased risk of nonserious bleeding. Withdrawal of aspirin was observed in up to 10% of perioperative acute cardiovascular syndromes.⁸
  • In a meta-analysis of >30000 patients with and without prior PCI undergoing NCS, antiplatelet therapy was associated with minimal bleeding risk and no increase in thrombotic complications.⁹
• In patients with coronary artery disease but without prior PCI who are undergoing elective noncarotid NCS, routine initiation of aspirin is not beneficial (Class 3 recommendation = Harm).
  • The POISE-2 trial randomly assigned 10,010 patients scheduled for noncardiac surgery and at risk of cardiovascular complications to receive perioperative aspirin or placebo. Taking aspirin before surgery and for 30 days afterward did not reduce the combined risk of death or nonfatal MI (7.0% versus 7.1%; HR, 0.99; P=0.92), but it was linked to a 23% higher risk of major bleeding.¹⁰

A Stepwise Approach to Perioperative Management

• The 2024 AHA/ACC guidelines advocate for a systematic approach to managing patients with coronary stents undergoing noncardiac surgery. Figure 1 summarizes an algorithmic approach to perioperative management of patients with coronary artery stents.

1. Assess the urgency of surgery: elective, time sensitive, urgent/emergent.
2. Evaluate the risk of stent thrombosis through evaluating the time elapsed since PCI, the type of stent, and the indication for PCI.
3. Assessment of surgical bleeding risk weighed against thrombotic risk if DAPT will need to be interrupted through a multidisciplinary discussion with surgery, anesthesiology, and cardiology.
4. A shared decision-making process, where the risks and benefits of the proposed plan are thoroughly discussed with the patient to ensure informed consent and alignment of care with patient preferences.