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Original Investigation | Association of VA Surgeons

Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery

Carla N. Holcomb, MD1,2; Robert H. Hollis, MD1,2; Laura A. Graham, MPH1,2; Joshua S. Richman, MD, PhD1,2; Javier A. Valle, MD3,4; Kamal M. Itani, MD5; Thomas M. Maddox, MD, MSc3,4; Mary T. Hawn, MD, MPH6
[+] Author Affiliations
1Department of Surgery, University of Alabama at Birmingham
2Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Hospital, Birmingham, Alabama
3VA Eastern Colorado Health Care System, Denver
4University of Colorado School of Medicine, Denver
5Department of Surgery, VA Boston Healthcare System, Boston University and Harvard Medical School, Boston, Massachusetts
6Department of Surgery, Stanford School of Medicine, Stanford, California
JAMA Surg. 2016;151(5):462-469. doi:10.1001/jamasurg.2015.4545.
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Importance  Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE).

Objective  To determine whether the clinical indication for a coronary stent is associated with postoperative MACE.

Design, Setting, and Participants  Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors.

Exposures  Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS).

Main Outcomes and Measures  Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization.

Results  Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P < .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication.

Conclusions and Relevance  Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.

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Figure 1.
Rates of Major Adverse Cardiac Events (MACE) by Time Between Coronary Stent Placement and Surgery, Stratified by Stent Indication

Stratification is by stent indication of myocardial infarction (A), unstable angina (B), and revascularization not associated with acute coronary syndrome (non-ACS) (C). Solid lines indicate estimated rates; shaded areas, 95% CIs. Density plots on the right show percentage of operations by time between percutaneous coronary intervention and operation.

Graphic Jump Location
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Figure 2.
Adjusted Odds of Major Adverse Cardiac Events by Stent Indication and Time From Percutaneous Coronary Intervention (PCI)

MI indicates myocardial infarction; non-ACS, revascularization not associated with acute coronary syndrome.

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