What Are the Role and Management of Percutaneous Coronary Intervention for Noncardiac Surgery?

INTRODUCTION

Percutaneous coronary intervention (PCI) has revolutionized the management of coronary artery disease (CAD), initially with balloon angioplasty (BA) and subsequently with coronary stenting, both with bare-metal stents (BMSs) and with drug-eluting stents (DESs). Historically, the high incidence of coronary restenosis from neointimal coronary endothelial growth plagued success rates for BA and prompted the clinical development and introduction of BMSs. Although a significant therapeutic advance, BMSs were still associated with coronary restenosis rates in excess of 20% in long-term follow-up studies . ^, The second major significant reduction in coronary restenosis after PCI came from DESs, which pharmacologically retard smooth muscle proliferation and migration with antimitotic agents, the main mechanisms behind in-stent restenosis. Despite this advantage, later follow-up studies found that there is a trade-off of an increase in the risk for stent thrombosis (ST) in first-generation DESs, which include the sirolimus- and pacitaxel-eluting stents, largely because of polymer-induced inflammation and thicker strut designs. Specifically, although the risks for early ST (within 30 days of implantation) in BMSs and first-generation DESs are similar, the risk for very late stent thrombosis (>1 year after implantation) was higher in these DESs. This heightened risk meant that patients receiving DESs would be consigned to an increase in dual antiplatelet therapy (DAPT) intensity and duration. Newer generations of DESs address these safety issues and have a 38% lower risk for clinically significant coronary restenosis, a 43% lower risk for ST, and a 23% lower risk for death compared with the older DESs. ^,

Since the introduction of second-generation DESs in 2008, millions of these devices have been implanted worldwide and have largely supplanted first-generation products. In a large cohort, the cumulative incidence of ST after 3 years was 1.5% in patients receiving BMS, 2.2% with first-generation DESs, and 1.0% in second-generation DESs. Nevertheless, the prevention of coronary ST in patients receiving any type of stent is of paramount importance because this complication has a high mortality rate. As a result, DAPT with aspirin and a P2Y ₁₂ inhibitor has been recommended for at least 1 month after BMS placement or for at least 6 months after DES placement in patients being treated for stable ischemic heart disease and for at least 1 year using the more potent P2Y ₁₂ inhibitors ticagrelor or prasugrel in patients receiving treatment for acute coronary syndrome (ACS). ^,

Although premature discontinuation of antiplatelet therapy is a major risk factor for ST, there are multiple other identified clinical and angiographic ischemic risk factors ( Table 11.1 ). ^{, , ,} The perioperative period qualifies as a major risk factor for ST and other types of myocardial ischemia because noncardiac surgery (NCS) activates platelets and induces hypercoagulability. ^, For example, cardiac risk was 27 times higher in the week after NCS (hazard ratio [HR]: 27.3; 95% confidence interval [CI]: 10.0–74.2; p < .001) in a large registry study. More recent observational data from Japan of 2398 patients found a 0.4% incidence of definite or probable stent thrombosis in the 30 days post-NCS, and a 3.2% composite rate of death, myocardial infarction (MI), and ST. Unfortunately, patients with coronary stents frequently require NCS. ^, Most of these surgeries are performed after the 1-year mark, although many surgeries are still necessary soon after stent implantation, as the cumulative incidence of surgery in a large multicenter trial was 3.6% at 30 days, 9.4% at 6 months, 14.3% at 1 year, and 40% at 5 years.

The danger of the perioperative period after recent PCI was known even in the early era of PCIs, highlighted in a small case series that documented a 20% mortality rate at 2 weeks in patients undergoing NCS within 40 days after BMS deployment, primarily from MI because of ST. Subsequently, in a large multicenter retrospective cohort of cases from 2000 to 2010, those who underwent NCS within 24 months of stent placement had higher rates of major adverse cardiac events (MACE) in the 30 days after surgery compared with those with stents who did not undergo surgery (3.1% versus 1.9%; risk difference [RD]: 1.3%; 95% CI: 1.0%–1.5%; p < .001). This risk difference was highest in the first 6 weeks after stent implantation (2.8%; 95% CI: 0.8%–4.8%). Thus the timing and management of perioperative patients with recent PCI is an important risk-benefit calculation. This chapter reviews the options, latest evidence, and current expert recommendations concerning the perioperative risk for recent PCI in NCS.

OPTIONS TO MINIMIZE STENT THROMBOSIS AFTER RECENT PERCUTANEOUS CORONARY INTERVENTION AND NONCARDIAC SURGERY

The perioperative options for limiting coronary thrombosis after recent PCI are presented in Table 11.2 . ^, The evidence for each option will be reviewed. Recent expert recommendations will be presented according to the schema of the American Heart Association (AHA) and American College of Cardiology (ACC), as outlined in Tables 11.3A (classes of recommendations) and 11.3B (levels of evidence). The expert recommendations and corresponding levels of evidence have been summarized in Tables 11.4 (class I recommendations), 11.5 (classes IIa and IIb recommendations), and 11.6 (class III recommendations). ^, The AHA/ACC guideline-focused update on duration of antiplatelet therapy in patients with coronary artery disease (2016) and perioperative cardiovascular care for NCS surgery (2014) are available at www.americanheart.org (section on guidelines and statements; last accessed May 1, 2021).

EVIDENCE