26 Nov Guidelines For Surgery After Cardiac Stents Have Improved Adverse Postoperative Outcomes

MedicalResearch.com Interview with
Dr. Mary T.  Hawn MD
Center for Surgical, Medical Acute Care Research, and Transitions,
Birmingham Veterans Affairs Medical Center
University of Alabama at Birmingham, Birmingham

Medical Research: What are the main findings?

Dr. Hawn: The main findings of the study are that the recommendations made in the guidelines published by the American College of Cardiology / American Heart Association in 2007 were effective at reducing postoperative major adverse cardiac events following noncardiac surgery in patients with a cardiac stent.¹  These guidelines recommended the delay of noncardiac surgeries in patients with a drug-eluting stent for 365 days if the surgery was not emergent or the delay of surgery for 4 to 6 weeks among patients with a bare metal stent.  In addition to a 26% reduction in postoperative major adverse cardiac events, we also found an increase in the time between drug-eluting stent placement and non-cardiac surgery consistent with the guideline recommendations.

Medical Research: Were any of the findings unexpected?

Dr. Hawn: In addition to our primary finding of a reduction in postoperative major adverse cardiac events, we also found evidence of a shift in cardiac risk to patients with a bare metal stent for surgeries occurring between 2006 and 2009.  Previous studies have suggested that differences in the outcomes of patients with a bare metal stent as compared to a drug-eluting stent are due to confounding by indication, where sicker patients needing more urgent operations were more likely to receive a bare metal stent and also more likely to experience adverse postoperative events.  This study provides evidence of a shift toward higher cardiac risk in patients with a bare metal stent following the initial publication in 2006 of several case reports of postoperative stent thrombosis in patients with a drug-eluting stent.

Medical Research: What should clinicians and patients take away from your report?

Dr. Hawn: While the recommendations were effective at increasing time between drug-eluting stent placement and surgery as well as reducing major adverse cardiac events, the trends in timing of surgery following drug-eluting stent placement suggest a high level of awareness among healthcare professionals treating patients with cardiac stents as well as an increased use of evidence-based practices.  This resulted in an increase in surgery timing for drug-eluting stent patients which can be seen prior to the publication of the guidelines.  While the publication of the guidelines marks a summary of this information into one document, it does not necessarily mark the time at which the information was officially available to healthcare providers in the field.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Hawn: Further study should be done to examine other factors influencing the management of patients with cardiac stents in need of subsequent surgery and their effect on outcomes.

1. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. Oct 23 2007;50(17):1707-1732.

Citation:
Improved Adverse Postoperative Outcomes With Revised American College of Cardiology/American Heart Association Guidelines for Patients With Cardiac Stents
Graham LA¹, Singletary BA¹, Richman JS¹, Maddox TM², Itani KM³, Hawn MT¹.
JAMA Surg. 2014 Nov 1;149(11):1113-20. doi: 10.1001/jamasurg.2014.2044.

Last Updated on November 26, 2014 by Marie Benz MD FAAD