Patterns of Antiplatelet Therapy During Noncardiac Surgery in Patients With Second-Generation Drug-Eluting Stents

Abstract

Background Continuing antiplatelet therapy (APT) has been generally recommended during noncardiac surgery, but it is uncertain if preoperative discontinuation of APT has been avoided or harmful in patients with second-generation drug-eluting coronary stents. Methods and Results Patients undergoing noncardiac surgery after second-generation drug-eluting coronary stent implantation were assessed in a multicenter cohort in Korea. Net adverse clinical events within 30 days postoperatively, defined as all-cause death, major adverse cardiac events, and major bleeding, were evaluated. Of 3582 eligible patients, 49% patients discontinued APT during noncardiac surgery. The incidence of net adverse clinical events was comparable between patients with continuation versus discontinuation (4.1% versus 3.4%; P=0.257) of APT during noncardiac surgery. Perioperative discontinuation of APT did not impact on net adverse clinical events (adjusted hazard ratio [HR], 1.00; 95% CI, 0.69-1.44; P=0.995). In subgroup analysis, patients undergoing intra-abdominal surgery were exposed to less risk of major bleeding by discontinuing APT (adjusted HR, 0.26; 95% CI, 0.08-0.91; P=0.035). Prolonged discontinuation of APT for ≥9 days was associated with higher risk of a major adverse cardiac event compared with continuing APT (adjusted HR, 3.38; 95% CI, 1.36-8.38; P=0.009). Conclusions APT was discontinued preoperatively in almost half of patients with second-generation drug-eluting coronary stents. Our explorative analysis showed that there was no significant impact of discontinuing APT on the risk of perioperative adverse events except that discontinuing APT may be associated with decreased hemorrhagic risk in patients undergoing intra-abdominal surgery. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT03908463.

Keywords: antiplatelet agent; stent; surgery.

Figures

Figure 1. Flow diagram of study participants.

CABG indicates coronary artery bypass graft; DES, drug‐eluting stent; NCS, noncardiac surgery; and PCI, percutaneous coronary intervention.

Figure 2. Cumulative incidence of perioperative adverse events comparing continuation vs discontinuation of antiplatelet therapy.

Net adverse clinical event (A), major adverse cardiac event (B), and major bleeding (C).

Figure 3. Forest plot of adjusted hazard ratio of discontinuing antiplatelet therapy for net adverse clinical event in subgroup analysis.

Cox proportional hazards model for net adverse clinical event was adjusted with diabetes mellitus, chronic heart failure, chronic kidney disease, anemia, high‐risk PCI, preoperative use of antiplatelet therapy and β‐blocker, urgent surgery, and surgical risk for cardiac and hemorrhagic risk. Center dots and whiskers indicate hazard ratios and 95% CIs, respectively. DAPT indicates dual antiplatelet therapy; and PCI, percutaneous coronary intervention.

Figure 4. Cumulative incidence of perioperative adverse events comparing continuation of antiplatelet therapy vs different durations of antiplatelet therapy discontinuation.

Duration of 4 to 8 days was determined to be associated with the lowest risk for net adverse clinical event by generalized additive model. Discontinuation for 1 to 3, 4 to 8, and ≥9 days was compared with continuing antiplatelet therapy in regard to net adverse clinical event (A), major adverse cardiac event (B), and major bleeding (C).