Antithrombotic therapy in patients at risk for coronary stent thrombosis undergoing non-cardiac surgery
Abstract
Percutaneous coronary interventions have become the most commonly performed coronary revascularization procedures. At the same time, the probability has been increased that patients with intracoronary stents will have to undergo surgery.
We can project that, in the Czech Republic, one thousand patients undergo non-cardiac surgery within six months of stent implantation annually. Two serious consequences emerge from this situation: (i) stent thrombosis in relation to discontinuation of antiplatelet therapy, and (ii) major bleeding in relation to continuation of antiplatelet therapy.
The best solution to overcome the risks resulting from surgery performed in patients after stent implantation is to postpone the procedure until after re-endothelialization of the vessel surface has been completed. Because only approximately 5-10% of surgeries are performed as an urgent procedure, this could be a signifi cant way to increase the safety of non-cardiac surgical procedures following stent implantation.
Expert recommendations advise that 3 months after bare-metal stent PCI and 12 months after drug-eluting stent PCI, patients can be sent for non-cardiac surgery while continuing aspirin therapy. Diffi cult decisions regarding antiplatelet management arise when a patient still on dual antiplatelet therapy with aspirin and thienopyridine (usually clopidogrel) has to undergo surgery which cannot be postponed.
A universal recommendation for this situation is unrealistic. Discussion among the attending cardiologist (cardiovascular risk), surgeon (the risk of bleeding), and the anesthesiologist (functional reserve, backup preparation) about this situation is recommended in order to achieve reasonable expert consensus.