glen j. kowalchuk, md, facc, fasci - atrium health · 2017. 7. 20. · mi ecabg mace bleeding...

S a n g e r H e a r t & Va s c u l a r I n s t i t u t e S y m p o s i u m 2 0 1 5

Cardiovascular Update For Primary Care Physicians

Glen J. Kowalchuk, MD, FACC, FASCI

My patient with a stent on dual antiplatelet therapyneeds surgery: interventional cardiologist please

advise

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Sanger Heart & Vascular Institute Symposium 2015

Disclosures

• Speakers bureau for: – Lilly – Daiichi Sankyo– Pfizer– Bristol Myers

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Effect of Recent Stenting on Surgical Outcomes

• 40 Patients with surgery 1-39 days after BMS– 8 of 25 patients within 2 weeks of stenting died ( 6 MI’s , 2 bleeds)– 0 of 15 patients died with surgery 15-39 days after stenting

• 207 patients undergoing surgery within 2 months after BMS– 8 of 207 patients died, suffered MI, or experienced stent thrombosis– All events occurred in the first 6 weeks– No events occurred in those from week 6 to week 8

J Am Coll Cardiol. 2000;35:1288‐1294

J Am Coll Cardiol. 2003;42:234‐240

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Incremental Risk of Non-cardiac Surgery on Adverse Cardiac Events Following Coronary Stenting

J Am Coll Cardiol. 2014;64(25):2730‐2739

Retrospective cohort analysis of 20,590 surgical vs. 41,180 nonsurgical patients 2000‐2010

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Stent Thrombosis

Pre‐Stent Post Stent 33 days Post Stent

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In Hospital Stent Outcomes with Aggressive Anticoagulation18

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12.5

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101214161820

ASA/dipyridamole ASA/dipyridamole/warfarin

SATMIECABGMACEBleeding

Schatz, et al. Circ 1991;83:148

n=39 n=174

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Stent Anticoagulation and Restenosis Study

N Engl J Med 1998;339:1665‐71

DES: Early Discontinuation of Anti-platelet Therapy is the Strongest Risk Factor for ST

Unstable angina

Thrombus Diabetes Unprotected left main

Bifurcation Renal failure

Prior brachy Rx

Premature antiplateletdiscont’d

Inci

denc

e (%

)

Iakovou et al. JAMA. 2005;293:2126.

N=2229 Overall stent thrombosis = 1.3%

HR 90Case fatality rate: 45%

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Surgical bleeding with ClopidogrelIn non-cardiac surgery, comparing patients taking clopidogrel and aspirin within 6 days of surgery (n=28) vs. those who stopped >6 days prior to surgery (n=22) experienced:

– More bleeding requiring transfusions 21.4% vs. 9.5%– Similar hospital stays, ICU stays, and mortality

104 patients receiving clopidogrel who underwent abdominal operations between March 2003 and March 2009. Patients were grouped by last clopidogrel use: group A (<7 days) and group B (≥7 days).

The Am Surg.74;8, August 2008:721‐725(5) Arch Surg. 2011;146(3):334-339

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Effect of Thienopyridine Use on Stent Thrombosis Following DES Implant

3021 patients after implant of 2853 SES or 2536 PES April 2002 to December 2004

Overall ST rate 1.9%

TCT 2006

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SPIRIT IV 1‐year results, Gregg Stone, TCT 2009

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5054 “real world” patients at 162 US sites‐ 37.5% ACS ‐ 40.8% multi‐vessel‐ 35.6% DM‐ 18.1% AMI‐ 11.1% CKD

J Am Coll Cardiol Intv 2011;4:1298–309

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Factors to Consider in Patients Undergoing Surgery Post Stent Implant

• Elective vs. urgent surgery• Complexity of surgery and risk of bleeding• Indications for initial stent implant• Type of stent initially implanted• Timing since stent implant

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Recommendations

• Delay surgery at least 6 months, if possible

• Continue DAPT or at least aspirin throughout the peri-operative period if early surgery is necessary

• Minimize the clopidogrel, prasugrel, or ticagrelor free interval as much as possible

• Communicate with surgical colleagues

glen j. kowalchuk, md, facc, fasci - atrium health · 2017. 7. 20. · mi ecabg mace bleeding...

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