Noncardiac surgery after percutaneous coronary intervention

INTRODUCTION — 

The management of patients who need noncardiac surgery and are on dual antiplatelet therapy (DAPT; ie, aspirin plus a P2Y₁₂ receptor blocker such as clopidogrel, prasugrel, or ticagrelor) after percutaneous coronary intervention (PCI) requires careful consideration of the perioperative risks of acute coronary events and bleeding. This topic will focus on choosing the most appropriate timing of surgery and managing antiplatelet therapy perioperatively.

The perioperative management of post-PCI patients who have completed their course of DAPT and who are taking aspirin without a P2Y₁₂ receptor blocker is discussed separately. (See "Management of cardiac risk for noncardiac surgery", section on 'Antiplatelet therapy'.)

The periprocedural management of post-PCI patients on DAPT who will be undergoing endoscopic procedures is discussed elsewhere. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures".)

The management of antiplatelet therapy in patients scheduled for coronary artery bypass graft surgery is presented separately. (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Preoperative aspirin' and "Coronary artery bypass surgery: Perioperative medical management", section on 'Platelet P2Y12 receptor blocker therapy'.)

A discussion of coronary artery stent thrombosis, which is the main potential complication of discontinuing antiplatelet therapy prematurely, is found elsewhere. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients" and "Coronary artery stent thrombosis: Incidence and risk factors".)

STANDARD DURATION OF ANTIPLATELET THERAPY AFTER PCI — 

Patients who undergo percutaneous coronary intervention (PCI) are prescribed dual antiplatelet therapy (DAPT; ie, aspirin plus a P2Y₁₂ receptor blocker such as clopidogrel, prasugrel, or ticagrelor). The purpose of DAPT is to reduce the risk of myocardial infarction, which is typically due to stent thrombosis in the first few months post-PCI.

The optimal duration of DAPT in patients who have undergone stenting depends on the patient’s individual risks for stent thrombosis and bleeding. Risk factors for stent thrombosis in patients after PCI include procedural-related (eg, stent and lesion characteristics) and clinical factors (eg, diabetes, chronic kidney disease, prior myocardial infarction). The type of stent (drug-eluting versus bare metal) does not appear to impact risk.

●DAPT is usually continued for at least 6 to 12 months in patients who have undergone stenting, and for at least one month in patients who have had balloon angioplasty. We determine the duration of DAPT based on the patient’s risks of bleeding and ischemic events, with a shorter DAPT duration reserved for patients without acute coronary syndromes or other ischemic risk factors.

●After DAPT therapy has been completed, we usually stop the P2Y₁₂ inhibitor and continue aspirin long-term. In some cases, however, we may choose to discontinue aspirin and maintain the patient on the P2Y₁₂ inhibitor.

For patients with a high bleeding risk, drug-coated balloons (DCBs) appear to be a promising alternative to drug-eluting stents because the risk of a thrombotic event may be lower than with stents, allowing for a shorter period of DAPT; however, the optimal duration of DAPT for patients undergoing DCB angioplasty has not been determined. (See "Patients with high bleeding risk undergoing percutaneous coronary intervention", section on 'Drug-coated balloon angioplasty'.)

A discussion about determining the appropriate DAPT duration after PCI can be found elsewhere. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on 'Our approach'.)

RISKS OF NONCARDIAC SURGERY AFTER PERCUTANEOUS CORONARY INTERVENTION — 

Given that approximately 5 to 10 percent of patients with coronary stents undergo noncardiac surgery within one year of stent implantation, clinicians must understand how to determine the appropriate timing of surgery (ie, whether and for how long surgery should be delayed) [1-5]. While perioperative treatment with antiplatelet therapy is associated with an increased risk of major bleeding, the discontinuation of one or both antiplatelet agents is associated with an increased risk of a thrombotic coronary event. The risks of thrombotic cardiac events and bleeding in this population are discussed below.

Thrombotic cardiac events — With the exception of surgical procedures that have a low bleeding risk (eg, cataract, dental, skin, breast, and hernia surgeries; cholecystectomy), discontinuation of P2Y₁₂ inhibitors is typically recommended before surgery. For patients on dual antiplatelet therapy (DAPT) who have undergone percutaneous coronary intervention (PCI) with stent placement, there is an increased risk of stent thrombosis if one or both antiplatelet agents are discontinued prematurely. Stent thrombosis is a highly morbid condition, with a 50 to 70 percent risk of myocardial infarction and a 10 to 40 percent mortality rate [6]. The premature cessation of DAPT is the strongest predictor of stent thrombosis. The risk of stent thrombosis is highest in the first 30 days after stent placement. Stent thrombosis is discussed in detail elsewhere. (See "Coronary artery stent thrombosis: Incidence and risk factors" and "Coronary artery stent thrombosis: Clinical presentation and management".)

Patients who undergo surgery appear to be at higher risk of stent thrombosis than those who do not undergo surgery, regardless of whether DAPT is continued perioperatively. This may be because surgery has prothrombotic and proinflammatory effects that predispose the coronary circulation to thrombosis, both at the site of prior stent placement and at other sites of atherosclerotic lesions [7-10]. The perioperative prothrombotic state may be mediated by increased platelet aggregation and decreased fibrinolysis [11-13].

In large, observational studies of patients who undergo major noncardiac surgery after PCI, early surgery (ie, within 6 to 12 months of PCI) is associated with an increased risk of adverse cardiovascular events. This association is particularly strong when surgery is performed within two to six weeks of PCI [1,4,5,14-22]. In a retrospective study of 28,089 patients who underwent noncardiac surgery within two years of stent placement, a shorter time between stent placement and surgery was associated with a higher risk of perioperative major adverse cardiovascular events (MACE) [5]. MACE rates for patients were as follows:

●Surgery less than six weeks after PCI: 11.6 percent

●Surgery between six weeks and six months after PCI: 6.4 percent

●Surgery between 6 and 12 months after PCI: 4.2 percent

●Surgery more than 12 months after PCI: 3.5 percent

However, there are several issues that impact the usefulness of these observational studies. These include confounding (ie, patients chosen for early surgery may be at higher risk for cardiovascular events than those who are not), lack of generalizability (ie, most studies involved patients with first-generation drug-eluting stents, which have a higher thrombosis risk than the later-generation stents that are currently used), and lack of information about perioperative interruption or continuation of DAPT in most of the studies.

The data that address perioperative DAPT management suggest that discontinuation of antiplatelet agents for surgery is associated with an increased risk of cardiac events. In an observational study of 666 stented patients who underwent surgery, multivariate analysis demonstrated that discontinuation of one or both antiplatelet agents was associated with increased cardiac events (odds ratio [OR] 25.8, 95% CI 3.37-198) [23]. By contrast, another study found comparable risks of cardiac events in those who took perioperative DAPT versus aspirin alone; however, the majority of the patients in that study had surgery more than one year after stent placement [24], when the risk of stent thrombosis is low.

Bleeding — There is evidence that undergoing surgery while taking one or more antiplatelet agents is associated with an increased risk of perioperative bleeding requiring transfusion. In a meta-analysis of 46 studies (38 observational and 8 randomized trials), an increased requirement for blood transfusion was observed in patients taking perioperative aspirin (risk ratio [RR] 1.14, 95% CI 1.03-1.26), clopidogrel (RR 1.22, 95% CI 1.06-1.41), and DAPT (RR 1.33, 95% CI 1.15-1.55) compared with patients who are not on antiplatelet agents [25]; transfusion requirements were similar between groups taking one or more antiplatelet agents. There is no high-quality evidence demonstrating that DAPT confers a higher perioperative bleeding risk than aspirin alone.

EMERGENT OR URGENT SURGERY — 

Surgery is defined as emergent if a delay of more than two hours poses an immediate threat to life, organ, or limb (algorithm 1). Surgery is defined as urgent if a delay of more than 24 hours poses a threat to life, organ, or limb [26].

If surgery is performed emergently or urgently on a patient who is taking a P2Y₁₂ inhibitor, the risk of bleeding is high. Perioperative platelet transfusions may be necessary if excessive bleeding occurs.

TIMING OF OTHER SURGERIES — 

If a time-sensitive or elective surgery is being considered, our approach depends on whether the patient has stents placed.

Patients with stents — The specific surgical procedure impacts our decision regarding the timing of elective surgery for patients with stents. Certain surgeries are more time-sensitive than others. The approach used by our authors reflect the recommendations in the perioperative guidelines from Europe and the United States, which have some differences [26,27]. We do not distinguish between drug-eluting and bare metal stents.

Time-sensitive surgery — Surgery is defined as time-sensitive if it may be delayed by up to three months without negatively impacting the patient’s prognosis (algorithm 1). If surgery is time-sensitive, our approach to determining the timing of surgery depends in part on the patient’s risk of stent thrombosis if the P2Y₁₂ inhibitor is interrupted prematurely. Certain features of the patient’s history and the percutaneous coronary intervention (PCI) procedure itself have been shown to increase a patient’s risk of stent thrombosis. These include the following [28]:

●Acute coronary syndrome within three months of PCI

●Prior stent thrombosis despite adequate antiplatelet therapy

●Chronic kidney disease

●Left ventricular ejection fraction <40 percent

●Diffuse multivessel disease in a patient with diabetes mellitus

●Stenting of the last remaining patent coronary artery

●At least three stents implanted

●At least three lesions treated

●Bifurcation stenting

●Total stent length >60 mm

●Treatment of a chronic total occlusion

When planning for time-sensitive surgery, we have a multidisciplinary conversation with the surgeon, cardiologist, anesthesiologist, and patient that takes into account the number of risk factors the patient has:

●For patients with one or more risk factors, we delay time-sensitive surgery until at least three months after PCI. For those at particularly high risk, some clinicians may elect to administer an intravenous antiplatelet agent (eg, cangrelor) while the oral P2Y₁₂ inhibitor is being withheld. Cangrelor is discussed in detail elsewhere. (See "Antithrombotic therapy for elective percutaneous coronary intervention: Clinical studies", section on 'Cangrelor'.)

●For patients without risk factors, our contributors' approaches are divided, reflecting the limited data in this setting and varying approaches in Europe and the United States. Some contributors delay for at least one month, while others delay for at least three months.

Perioperative platelet management is discussed below. (See 'Perioperative antiplatelet management' below.)

Elective surgery — Elective surgery is defined as any surgery that is not emergent, urgent, or time-sensitive (algorithm 2). As with time-sensitive surgery, the presence or absence of risk factors for stent thrombosis impacts the optimal timing of elective surgery. A list of risk factors for stent thrombosis can be found above. (See 'Time-sensitive surgery' above.)

●For patients with one or more risk factors for stent thrombosis, we usually delay elective surgery until 6 to 12 months after PCI.

●For patients without risk factors, we usually delay elective surgery until three to six months after PCI.

When choosing the appropriate timing of surgery within the ranges listed above, we consider the indication for surgery and the patient’s preference. As an example, a patient with debilitating hip pain might wish to proceed with hip replacement surgery as soon as possible and might therefore accept a higher risk of perioperative myocardial infarction, while someone with less severe symptoms might decide to delay surgery for longer to minimize the risk of myocardial infarction.

Perioperative platelet management is discussed below. (See 'Perioperative antiplatelet management' below.)

Patients with balloon angioplasty — Fewer than 5 percent of all PCIs are performed using percutaneous balloon angioplasty without stent placement. Many of these patients are treated with one month of dual antiplatelet therapy (DAPT), although there are no randomized trials to support this approach. We suggest waiting to perform surgery until the patient has completed at least 14 days of DAPT. (See 'Perioperative antiplatelet management' below.)

PERIOPERATIVE ANTIPLATELET MANAGEMENT — 

To balance the perioperative risk of bleeding with the risk of cardiac events, our approach to antiplatelet therapy is as follows:

●For post-percutaneous coronary intervention (PCI) patients, we generally continue aspirin throughout the perioperative period to reduce the risk of perioperative myocardial infarction; however, an exception may be required for a patient who is undergoing surgery that confers a high risk of bleeding complications, such as intracranial, spinal, and intraocular surgeries.

In a subgroup analysis of the POISE-2 trial that included 470 patients with prior PCI who underwent noncardiac surgery, perioperative aspirin reduced the risk of myocardial infarction (absolute risk reduction 5.9%, 95% CI 1-10.8) [29]. Although there was an absolute increase in major and life-threatening bleeding of 1.3 percent, this difference was not statistically significant. This trial excluded patients who were within one year of a drug-eluting stent or six weeks of a bare metal stent, as these patients required dual antiplatelet therapy (DAPT). Other aspects of the POISE-2 trial are discussed elsewhere. (See "Management of cardiac risk for noncardiac surgery", section on 'Antiplatelet therapy'.)

●In most cases of elective or time-sensitive surgery, we suggest holding P2Y₁₂ inhibitors given the increased risk of perioperative bleeding with antiplatelet agents (see 'Bleeding' above). However, if surgery is taking place within three months of drug-eluting stent placement and the risk of bleeding is not excessive, it may be reasonable to continue the P2Y₁₂ inhibitor perioperatively [26].

We discontinue each medication as follows:

•Prasugrel: Stop the medication seven days before surgery

•Clopidogrel: Stop the medication five days before surgery

•Ticagrelor: Stop the medication three to five days before surgery

We restart the P1Y12 inhibitor as soon as the surgeon deems it safe to do so, generally within 48 hours. We use standard P2Y₁₂ inhibitor loading doses. (See "Antithrombotic therapy for elective percutaneous coronary intervention: General use".)

●For post-PCI patients who are not already taking aspirin (eg, patients taking an oral anticoagulant with or without a P2Y₁₂ inhibitor), we suggest perioperative treatment with low-dose aspirin, given improvements in mortality [29] as discussed above.

The perioperative management of aspirin for patients without a history of PCI (eg, patients without prior PCI taking aspirin for primary or secondary prevention) is discussed in detail elsewhere. (See "Management of cardiac risk for noncardiac surgery", section on 'Antiplatelet therapy'.)

PERIOPERATIVE MANAGEMENT OF OTHER CARDIAC MEDICATIONS — 

The perioperative management of other medications that patients often take after PCI (eg, beta blockers, statins, angiotensin-converting enzyme inhibitors) is discussed elsewhere. (See "Management of cardiac risk for noncardiac surgery", section on 'Beta blockers' and "Management of cardiac risk for noncardiac surgery", section on 'Other medical therapies'.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Perioperative cardiovascular evaluation and management".)

SUMMARY AND RECOMMENDATIONS

●Background – Noncardiac surgery is often proposed for patients taking dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). The management of these patients requires careful consideration of the perioperative risks of acute coronary events and bleeding. The risk of a perioperative cardiac event is highest in the first month after PCI and decreases over the next few months. (See 'Introduction' above and 'Risks of noncardiac surgery after percutaneous coronary intervention' above.)

●Emergent/urgent surgery – If a patient who is taking a P2Y₁₂ inhibitor needs emergent or urgent surgery (ie, within 24 hours), the surgeon should anticipate an increased risk of bleeding. Perioperative platelet transfusions may be necessary if excessive bleeding occurs. (See 'Emergent or urgent surgery' above.)

●Timing of other surgeries in patients with stents

•Time-sensitive surgery – Surgery is time-sensitive if it may be delayed by up to three months without negatively impacting outcomes (algorithm 1). For patients with stents who have at least one risk factor for stent thrombosis, delaying time-sensitive surgery until at least three months after PCI helps to mitigate these risks. For patients with stents who do not have any risk factors, delaying for one to three months after PCI (Grade 2C). The indications for time-sensitive surgery are heterogeneous, with some meriting surgery sooner than others. A multidisciplinary discussion (including surgeon, cardiologist, anesthesiologist, and patient) is appropriate for all patients with stents undergoing time-sensitive surgery. (See 'Time-sensitive surgery' above.)

•Elective surgery – Surgery is elective if it may be delayed by more than three months without negatively impacting outcomes (algorithm 2). For patients with stents who have at least one risk factor for stent thrombosis, delaying elective surgery for 6 to 12 months after PCI is appropriate. For most patients with stents who do not have any risk factors, delaying elective surgery for three to six months after PCI is sufficient. (See 'Elective surgery' above.)

●Timing of other surgeries in patients with balloon angioplasty – We typically delay surgery until at least 14 days after balloon angioplasty. (See 'Patients with balloon angioplasty' above.)

●Perioperative antiplatelet therapy management

•For patients undergoing surgery (other than for surgery with a low bleeding risk), we suggest holding the P2Y₁₂ inhibitor prior to the procedure (Grade 2C). We hold the drug for a minimum of seven days for prasugrel, five days for clopidogrel, and three to five days for ticagrelor. (See 'Perioperative antiplatelet management' above.)

•We continue aspirin perioperatively for most post-PCI patients. In patients for whom a bleeding complication could be catastrophic, such as those undergoing intracranial, spinal, and intraocular surgeries, stopping aspirin may be reasonable.

•For post-PCI patients who are not taking aspirin (eg, those who are taking an oral anticoagulant either alone or with a P2Y₁₂ inhibitor), we suggest perioperative treatment with low-dose aspirin while the other medications are being held (Grade 2C). (See 'Perioperative antiplatelet management' above.)