Bare-metal stents best

Monday 21st May 2007

Bare-metal stents (BMSs) should be used rather than drug-eluting stents (DESs) for coronary revascularisation in patients needing noncardiac surgery shortly afterwards, US researchers say.

The team, led by Dr Michael Savage of Philadelphia's Thomas Jefferson University Hospital, found that a strategy involving BMS implantation in the revascularisation procedure did not result in stent thrombosis after subsequent noncardiac surgery, a common problem with DESs in this setting.

Coronary artery disease (CAD) is often discovered, particularly in elderly patients, in presurgical testing for elective noncardiac procedures. If severe, this represents an immediate problem that must be treated before the patient undergoes elective surgery.

"The issue here is that studies have demonstrated that those patients who receive DESs may develop life-threatening cardiac complications if they undergo subsequent, noncardiac surgery," Dr Savage explained.

In particular, with DESs there is an increased risk of fatal myocardial infarction (MI) due to stent thrombosis, even when surgery is performed months or years after stent placement, especially if antiplatelet therapy is stopped before surgery.

Dr Savage and team developed a four-stage clinical protocol, based on the known timing of re-endothelialisation and restenosis of the target vessel after BMS implantation. The strategy involved: use of non-DESs; a four-week course of clopidogrel after revascularisation; deferral of noncardiac surgery for 5–12 weeks after stenting; and discontinuation of clopidogrel for a minimum of five days prior to surgery.

The strategy was evaluated in 60 consecutive patients with significant CAD (33 men and 27 women) who underwent percutaneous coronary intervention (PCI) prior to planned noncardiac surgery. The patients were aged on average 68 years and 27% had diabetes.

Presenting the findings at the Annual Scientific Sessions of the Society for Cardiovascular Angiography and Interventions, held in Orlando, USA, the researchers reported that 82 lesions were treated with 83 BMSs.

PCI was successful and uncomplicated in all 60 patients. Noncardiac surgery was performed on average 47 days post-PCI, with clopidogrel discontinued a mean of six days beforehand.

No deaths occurred after noncardiac surgery, there was no ST-elevation MI and there were no stent thrombosis events.

The only perioperative cardiac complication was non-ST-elevation MI in one patient, which led to target vessel revascularisation of a new lesion, the researchers noted.

"This research provides a safe treatment strategy for interventional cardiologists and their patients who will be undergoing further surgery," Dr Savage said. "DESs have proven benefits but may not be the best solution for every patient."

Society for Cardiovascular Angiography and Interventions Annual Scientific Sessions, Orlando, Florida, USA, 9–12 May 2007