Noncardiac surgery in patients with coronary artery stents.

T HE MANAGEMENT OF PATIENTS WHO UNdergo coronary artery stent implantation and subsequently require noncardiac surgery is a real and challenging clinical problem. In 2008, more than 800 000 percutaneous coronary procedures were performed in the United States, with coronary stents implanted in over 96% of cases. Approximately 5% of patients undergo noncardiac surgery in the 12 months following coronary stent implantation. Patients undergoing noncardiac surgery following coronary artery stent implantation are at increased risk of adverse cardiovascular events in the perioperative period. Large-scale retrospective studies have reported an overall incidence of death or major adverse cardiac events of 2% to 9%, although the risk seems even higher when surgery is performed early after stent implantation. This increased risk relates in part to the underlying atherosclerotic burden, the prothrombotic and proinflammatory effects of surgery, and the risk of perioperative stent thrombosis. Stent thrombosis is a serious complication associated with poor clinical outcomes; 1 in 5 patients die and more than two-thirds experience a clinically significant myocardial infarction. Premature discontinuation of antiplatelet therapy has emerged as one of the most powerful independent predictors of stent thrombosis, but other factors, such as stent malapposition, delayed endothelization, and hypersensitivity reactions, have also been implicated. Stent thrombosis is of particular concern in patients in whom drug-eluting stents, used in over 60% of percutaneous coronary interventions in the United States in 2008, are implanted. Coated with an antiproliferative drug designed to inhibit neointimal hyperplasia, drugeluting stents have successfully reduced rates of restenosis at the expense of a small but significant increase in the risk of very late ( 1 year) and possibly late (30 days to 1 year) stent thrombosis. As a result, in contrast to the 4 weeks recommended following bare metal stent implantation, current European and US guidelines recommend 6 to 12 months of dual antiplatelet therapy following placement of a drug-eluting stent. The decisions around the need for and timing of noncardiac surgery in patients with recently implanted coronary stents can be complex and are best considered on an individual basis with a multidisciplinary approach involving the surgeon, cardiologist, and anesthesiologist. To aid decision-making, evidence is emerging in support of some general principles summarized recently in a number of national and international guidelines (Table). PROPHYLACTIC CORONARY REVASCULARIZATION