-- M E M O R A N D U M --
To : SPR Medical Staff
Jay Duggins, MD, Presbyterian Anesthesia Associates
From: Bob Iwaoka, MD, Mid Carolina Cardiology
Gary Niess, MD, Mid Carolina Cardiology
Tom Zweng, MD, SVP and Chief Medical Officer, SPR
Date: January 11, 2012
Re: Guidelines for timing of elective noncardiac procedures and discontinuation of
anti-platelet therapy in patients with coronary artery stents
Patients with Intracoronary stents having noncardiac surgery are at increased risk of stent
thrombosis. Stent thrombosis is a sudden catastrophic event for the patient which carries a
mortality rate of up to 40%. Patients who survive this event often are left with a severely
dysfunctional heart. Over time, an intracoronary stent is covered with endothelium resulting in
lowered risk: the amount of time from placement depends on many factors including type of
stent, lesion involved, and patient’s diseases. The stress response of surgery includes a prothrombotic state promoting the formation of a stent thrombus. An investigation from the Mayo
Clinic found a 5% incidence of major adverse cardiac events in patients with drug-eluting stents
undergoing noncardiac surgery within 12 months from time of stent placement (1).
Dual anti-platelet therapy (DAPT) effectively reduces the risk of stent thrombosis to 1%. A
thienopyridine (commonly prescribed clopidogrel [Plavix, Sanofi-Aventis] or prasugrel [Effient,
Eli Lilly] or ticagrelor [Brilinta (Astra Zenica]) and aspirin are administered concomitantly. The
patient’s attending cardiologist should manage the dual anti-platelet therapy perioperatively.
This medical decision requires their expertise on judging the above mentioned factors. In some
of these cases, the risk of AST will have to be weighed against the risk of surgical bleeding,
particularly where bleeding into a closed space is possible.
Many surgical practices routinely instruct their noncardiac surgical patients to stop Plavix or
Effient or Brilinta and aspirin prior to surgery. Preoperative instructions need to be modified for
patients with intracoronary stents to continue dual anti-platelet therapy until specific orders are
given by the patient’s cardiologist. Two large multi-disciplinary national task forces have
published recommendations concerning this clinical scenario (2, 3). The following directives are
taken from them and should be applied to our patients at the Presbyterian Hospitals.
1. All elective surgery should be delayed for:
a. 6 weeks from the time of bare-metal stent placement,
b. 365 days from the time of drug-eluting stent placement.
2. All stent patients should see a Cardiologist pre-operatively for “start/stop”
recommendations for Plavix /Brilinta /Effient and aspirin.
3. Except for neurosurgical and urologic procedures, aspirin should continue and NOT
be stopped in the peri-operative period in any patient who has ever had a coronary
stent.
a. 81 mg of aspirin is protective and poses minimal operative bleeding risk.
4. Warfarin, Lovenox and heparin are NOT protective against cardiac events in stent
patients. Only aspirin plus thienopyridine therapy has been shown to be efficacious
in preventing stent thrombosis.
5. Patients with coronary artery stents who are still managed on Plavix/Brilinta
/Effient may not have surgery performed at the following Ambulatory Surgical
Centers (ASCs – Midtown, Southpark, Huntersville, Monroe, and Ballantyne).
Exceptions to this ASC exclusion are patients for Cataract removal who have been
cleared by their cardiologist and remain taking Aspirin therapy perioperatively.
It is important that any patient with a coronary stent undergo a consult from their cardiologist to
develop the protocol for dual anti-platelet therapy in the perioperative period.
If you have any further questions or concerns, please contact Bob Iwaoka, MD, Ed McMillian
MD, Jay Duggins, MD, or at Presbyterian Matthews, Gary Niess, MD.
References:
1. Rabbitts et. al. Cardiac risk of noncardiac surgery after percutaneous coronary
intervention with drug-eluting stents. Anesthesiology 2008; 109:596-604.
2. Grines et al. Prevention of premature discontinuation of dual anti-platelet therapy in
patients with coronary stents: A science advisory from the American Heart Association,
American College of Cardiology, Society of Cardiovascular Angiography and
Interventions, American College of Surgeons, and American Dental Association, with
representation from the American College of Physicians. Circulation 2007; 115:813-8.
3. Fleisher et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery. Circulation 2007; 116:e418-99.
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