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Delaying Elective Surgery After Stent Implants Significantly Reduces Potential Complications E-mail
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A pair of studies directed by anesthesiologists from Mayo Clinic provides important new guidance for patients with coronary stents who are electing to have surgery.

Gregory A. Nuttall, M.D., and his group from the Mayo Clinic College of Medicine, Rochester, evaluated 899 patients from 1990 to 2005 who had received coronary artery stents. Their research indicates that elective non-cardiac surgery performed 90 days or more after implantation of coronary stents offers the lowest risk of surgery-related death, heart attack and the need for re-opening clotted artery stents.

Coronary artery stents, whether made of metal or of a kind that leak drugs into the bloodstream, are used to open blocked arteries and restore blood flow to the heart.

This research underscores a quandary faced by an increasing number of physicians dealing with the needs of an aging population: Blood-thinning medications used to prevent clots in artery stents increase the risk of surgical bleeding, but if the medication is stopped before surgery, the patient is predisposed toward stent closure, angina and heart attacks.

According to Charles W. Hogue, Jr., M.D., who wrote an accompanying editorial for the study, it is important that any exposed metal in artery stents be allowed enough time to be covered by the blood vessels' endothelial cells, and it's critical that a "dual therapy" of blood-thinning drugs such as aspirin or clopidogrel be administered to keep clots from forming in the stent.

"It is now recognized that premature discontinuation of duel blood antiplatelet therapy during this critical period is a major independent risk factor for blood clotting," said Dr. Hogue.

In response to these risks, the American College of Cardiology released a scientific advisory in 2007 that includes a recommendation to delay elective non-cardiac surgery for one year after implantation of artery stents and recommends uninterrupted blood-clotting therapy for a minimum of one month after metal stent implantation and a minimum of one year after drug-leaking stent implantation. These recommendations were based on several small studies with small sample sizes.

Dr. Nuttall's two large studies, though, represent the largest series of patients currently reported.

"Our first study found that the risk of death, heart attack and need for re-opening a clotted coronary artery stent was 1 in 10 patients if surgery was performed 30 days or less from placement of a bare metal stent," said Dr. Nuttall. "From the time period of 30 to 90 days, the number dropped to 1 in 25 patients. And after 90 days, it dropped to 1 in 33 patients."

In a related study of drug leaking stents completed at the same time, Dr. Nuttall found that the incidence of death, heart attack and the need to re-open clotted artery stents was 6 percent throughout the first year after implantation and dropped to 3 percent during the second year.

"These two studies add to a growing body of literature demonstrating that timing really is everything when considering the risks and management strategy of non-cardiac surgery in patients with coronary stents," said Dr. Hogue.

For more information visit the Anesthesiology Web site at http://www.anesthesiology.org/ and the American Society of Anesthesiologists Web site at http://www.asahq.org/.

Founded in 1905, the American Society of Anesthesiologists is an educational, research and scientific association with 43,000 members organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

About Heart Disease

Heart disease is a broad term that includes several more specific heart conditions. These conditions include:
  • Arrhythmias. Irregular, or abnormally fast or slow, beating of the heart. The heart beat is controlled by electrical impulses. When the timing or frequency of these electrical impulses are disrupted, arrhythmias develop. Some arrhythmias are quite serious. An example is ventricular fibrillation, a severely abnormal heart rhythm that causes death unless treated right away by providing an electrical shock to the heart (called defibrillation). Others are less severe but can develop into more serious conditions over time. A particular concern is atrial fibrillation. Atrial fibrillation is rapid, irregular beating of the upper chambers of the heart. The chambers can quiver instead of beating in a regular pattern. Blood is not fully pumped out of them and may pool and clot.
  • Cardiomyopathy. A weakening of the heart muscle or a change in heart muscle structure. It often results in inadequate heart pumping or other heart function abnormalities. These can result from various causes, including prior heart attacks, viral or bacterial infections, and others.
  • Congenital Heart Disease. Malformations of heart structures, present during pregnancy or at birth. These may be caused by genetic factors or by adverse exposures during pregnancy. Examples include holes in the walls that divide the heart chambers, abnormal heart valves, and others. Congenital heart defects can disrupt the normal flow of blood through the heart. Congenital heart defects are the most common type of major birth defect.
  • Coronary Heart Disease (CHD). CHD is the most common type of heart disease. CHD occurs when the coronary arteries, that supply blood to the heart muscle, become hardened and narrowed due to the plaque buildup. The plaque buildup and the narrowing and hardening of the arteries is called atherosclerosis. Plaques are a mixture of fatty substances including cholesterol and other lipids. Blood flow and oxygen supply to the heart can be reduced or even fully blocked with a growing plaque. Plaques may also rupture and cause blood clots that block arteries. CHD can lead to a heart attack. Angina, the most common symptom of CHD can also occur. Angina is chest pain or discomfort that occurs when the heart muscle is not getting enough blood. Irregular heart beats, called arrhythmias, can develop. Over time, CHD can weaken the heart muscle and lead to heart failure, a serious problem where the heart cannot pump blood the way that it should.
  • Heart Attack. A heart attack, also called a myocardial infarction may occur when blood supply to the heart is severely reduced or completely blocked. When blood flow is restricted the heart muscle cells do not receive enough oxygen and begin to die. The more time that passes without treatment to restore blood flow, the greater the damage to the heart. This damage can cause irregular heart rhythms or even sudden cardiac arrest or stopping of the heart beat. Death can result. Coronary artery disease is the chief underlying cause of a heart attack. A less common cause of a heart attack is a severe spasm of a coronary artery that reduces the blood supply to the heart.
  • Heart Failure. This may also be called congestive heart failure or chronic heart failure. Heart failure is a condition where the heart cannot pump enough blood and oxygen to meet the needs of other body organs. Heart failure does not mean that the heart has stopped, but that it cannot pump blood the way that it should. Heart failure is a serious condition. There is no cure for heart failure at this time, except a heart transplant. Once diagnosed, medicines are needed for the rest of the person's life. See our heart failure fact sheet.
  • Peripheral Arterial Disease (PAD). Hardening of the arteries that supply blood to the arms and legs. PAD is usually the result of atherosclerosis, the buildup of plaque and narrowing of the arteries. Blood flow and oxygen to the muscles in the arms and legs can be reduced or even fully blocked. Painful leg muscles, numbness, swelling in the ankles and feet, and weak pulse in the feet are some of the signs and symptoms of PAD.
  • Rheumatic Heart Disease. This condition is damage to the heart valves and other heart structures due to inflammation and scarring caused by rheumatic fever, which occurs from streptococcal infection. Heart disease is an umbrella term for a number of different diseases affecting the heart. Heart disease is a number of abnormal conditions affecting the heart and the blood vessels in the heart.
 
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