BJA Advance Access originally published online on May 2, 2006
British Journal of Anaesthesia 2006 96(6):686-693; doi:10.1093/bja/ael083
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Coronary artery stenting and non-cardiac surgery—a prospective outcome study
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1 Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz Austria
2 Department of Anaesthesiology and Intensive Care Medicine, General Hospital Linz Austria
3 Department of Anaesthesiology and Intensive Care Medicine, County Hospital Leoben Austria
4 Department of Anaesthesiology and Intensive Care Medicine, University of Pennsylvania Health Systems Philadelphia, USA
*Corresponding author. E-mail: martin.vicenzi{at}meduni-graz.at
Accepted for publication March 7, 2006.
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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Background. A 45% complication rate and a mortality of 20% were reported previously in patients undergoing non-cardiac surgery after coronary artery stenting. Discontinuation of antiplatelet drugs appeared to be of major influence on outcome. Therefore we undertook a prospective, observational multicentre study with predefined heparin therapy and antiplatelet medication in patients undergoing non-cardiac procedures after coronary artery stenting.
Methods. One hundred and three patients from three medical institutions were enrolled prospectively. Patients received coronary artery stents within 1 yr before non-cardiac surgery (urgent, semi-urgent or elective). Antiplatelet drug therapy was not, or only briefly, interrupted. Heparin was administered to all patients. All patients were on an intensive/intermediate care unit after surgery. Main outcome was the combined (cardiac, bleeding, surgical, sepsis) complication rate.
Results. Of 103 patients, 44.7% (95% CI 34.9–54.8) suffered complications after surgery; 4.9% (95% CI 1.6–11.0) of the patients died. All but two (bleeding only) adverse events were of cardiac nature. The majority of complications occurred early after surgery. The risk of suffering an event was 2.11-fold greater in patients with recent stents (<35 days before surgery) as compared with percutaneous cardiac intervention more than 90 days before surgery.
Conclusions. Despite heparin and despite having all patients on intensive/intermediate care units, cardiac events are the major cause for new perioperative morbidity/mortality in patients undergoing non-cardiac surgery after coronary artery stenting. The complication rate exceeds the re-occlusion rate of stents in patients without surgery (usually <1% annually). Patients with coronary artery stenting less than 35 days before surgery are at the greatest risk.
Keywords: complications, stent thrombosis; procedure, percutaneous coronary intervention (PCI); risk, perioperative
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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In 1987, Sigwart and colleagues1 published a series of successful percutaneous cardiac interventions (PCIs) with stent implantation. Since then, numerous publications of PCI followed, initiating one of the greatest and persistent success stories in cardiology.2–6 Nowadays, PCI with stenting is used as a routine treatment of coronary artery disease. Stent design and materials, implantation techniques and periprocedural antiplatelet drug regimens are persistently evolving.
There was a lag of 13 yr after the initial publication of Sigwart and colleagues,1 until the first reports appeared suggesting that PCI may have disadvantages in patients later undergoing non-cardiac surgery.7–10 Kaluza and colleagues7 drew attention to the problem by reporting an alarming 20% perioperative mortality rate in patients undergoing surgical procedures after PCI with stenting.7 Furthermore, perioperative alteration of the concomitant, mandatory antiplatelet therapy appeared to be of crucial importance to Kaluza and colleagues.
The main goal of this prospective, three-centre study was to identify the number, the type, the severity and the time of occurrence of adverse events in a group of patients with recent coronary stent placement.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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After gaining permission from the Institutional Review Boards/Ethics Committees, patients from three medical institutions in Austria were enrolled in this prospective, observational study. Enrolment was between October 2001 and February 2004. To be eligible, patients had to have coronary artery disease treated by PCI and stenting within 12 months before any non-cardiac, surgical procedure. Recruitment into the study was on the day before surgery. None of the patients was prophylactically stented before surgery. All urgent, semi-urgent or elective procedures, be it minor, intermediate or major surgery, were included.11 All patients had to have troponin plasma concentrations (cTnT) below the detection limit (<0.01 ng ml–1 plasma; Troponin T Stat, Roche, Vienna, Austria) at induction of anaesthesia. Patients having PCIs longer than a year ago were excluded.
An institutional guideline regarding heparin and antiplatelet drugs had to be applied and chosen at the discretion of the attending physicians on the wards: the requirement was to continue antiplatelet therapy (aspirin ± clopidogrel) throughout the perioperative period, or to discontinue it for less than 3 days before operation, and additionally all patients received unfractionated heparin continuously in a therapeutic dose [>1.5-fold activated partial thromboplastin time (aPTT)], or alternatively use enoxaparin (at least 1 mg kg–1 day–1) s.c. This ensured that all patients received heparin and that antiplatelet drugs were continued or only shortly discontinued.
Anaesthetic management was left to the discretion of the attending anaesthetists. Comparable monitoring capabilities were required at the study sites, including multi-channel ECG with ST segment analysis, measures of cardiac enzymes, of cTnT (at induction, on postoperative days 1 and 2, as indicated) and echocardiography as needed. Biochemical tests were performed through identical routines of the laboratories at the study sites. After operation, all patients had to be transferred to an intensive care unit (ICU) or intermediate care unit (IMC) at least overnight to closely monitor for postoperative signs of myocardial ischaemia (ST segment changes, arrhythmias, clinical symptoms) and other complications (surgical, sepsis). In case of a cardiac event, the attending cardiologist determined further evaluation, medical or interventional treatment. During hospitalization, a study protocol and the patients' records were used for data documentation and collection. After release, all hospital records, the medical correspondence with other institutions and physicians, and a phone interview (at least 3 months after surgery) were used to detect out-of-hospital events.
The main outcome variable was the combined (cardiac, bleeding, surgical, sepsis) perioperative complication rate during their hospital stay and for at least 3 months after surgery. The definitions of the various types of cardiac complication have been published previously and include the following:12
- cardiac death,
- myocardial infarction,
- re-PCI or coronary artery bypass graft (CABG) surgery,
- congestive heart failure,
- new unstable angina,
- new, significant arrhythmias and
- myocardial cell injury13 (cTnT >0.035 ng ml–1 plasma without other signs of myocardial infarction).
Exaggerated bleeding and unusually high postoperative blood loss were defined by the surgeon.
All data were entered in a database/statistics program (StatView, Abacus Concepts, Berkeley, USA) for further evaluation and presentation in tables and graphs. Numerical data were tested for normal distribution to determine the appropriate comparative tests. During the initial data analyses, univariate comparisons, using t-tests or rank sum test as appropriate, were performed to detect the differences between patients with events and event-free patients. For the distribution of categorical or binary data between groups, 
2-analysis was used. The time interval between surgery and a primary outcome event was calculated, whereby not the first, but the most severe adverse event was considered (in case of more than one event occurring in one patient). These time intervals were depicted in a cumulative event time curve (Kaplan–Meier). The event time curve was separated, according to the time span between PCI and surgery (PCI less than 35 days before surgery, between 35 and 90 days and longer than 90 days before surgery). This separation was based on the cardiological recommendation and practice, that aspirin should be combined with clopidogrel for 1–3 months. The three event time curves were further analysed using log-rank tests. In a subsequent analysis, covariates and cofactors (listed in Table 1) were introduced in the event time analyses using the multivariate approach provided by the Cox Proportional Hazards Model, in order to detect confounding influences of these cofactors/covariates (listed in Table 1). The level of significance was set at P < 0.05.
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Results |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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One hundred and three patients were prospectively enrolled at three study sites. One site was a university hospital (n=73 patients), one an academic teaching hospital (n=27) and one a major county hospital (n=3), all of them having the capability of performing PCIs. Three additional patients did not enter further data collection or analyses because surgery was cancelled or postponed for an unknown period.
Considering the study institutions, the 103 patients represent approximately 5% of the number of PCIs performed annually, suggesting that 5% of patients who underwent PCI within the past year will also undergo non-cardiac surgery. Based upon data from the preoperative clinic this number would at least triple when considering all patients with a history of PCI and stenting at any time.
Baseline characteristics of the patients, co-morbidities, type of surgery and concomitant medication at inclusion, and primary endpoints of this study are presented in Table 1. Variables listed in this table also serve as covariates or cofactors in the event time analyses. The median follow-up after surgery was 399 days (range 93–912 days).
In 37 cases, PCI had been performed in the left anterior descending coronary artery, in 27 cases in the circumflex, in 36 in the right and in one case in the left main stem coronary artery. Twenty-one patients carried more than one stent. In 16 patients, the location of the stent remained unclear. Although 25 bare metal stents and 5 drug-eluting ones were identified; in 79 cases, stent identification remained impossible because of poor documentation.
Surgical procedures included the whole spectrum of non-cardiac cases. Therefore there was a wide range of duration of anaesthesia as presented in Table 1.
Nearly half of the patients (46 of 103, 44.7%, 95% CI 34.9–54.8) suffered an adverse event. Two patients had significant bleeding as the only event of interest; two additional patients suffered a cardiac event as defined in the Patients and methods section and unusually high blood loss as determined by the surgeon. In total, 58 units of packed red blood cells were used in total (range 0–6 per patient). The remaining patients suffered only cardiac events in their perioperative course. Nine patients suffered two cardiac events. These multiple events occurred on the same day (n=6) or within 1 day delay (n=3). Five cardiac events were fatal (mortality rate 4.85%, 95% CI 1.6–11.0). Adverse events other than cardiac complications or bleeding did not occur.
The time of occurrence of adverse events is depicted by the Kaplan–Meier event time curve in Figure 1A. This curve demonstrates that many adverse events occur early after surgery. However, adverse events still occur as time progresses; albeit at a lower rate.
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Patients characteristics, duration and type of anaesthesia or surgery, urgency, co-morbidity, angina, New York Heart Association (NYHA) classification and concomitant medication (inclusive of the intake of antiplatelet agents) were not statistically different in direct comparisons between patients with and without adverse events. Yet, the time span between PCI and surgery was shorter (P=0.045) in patients with adverse events than in patients without adverse events (Table 1).
To gain more insight into the influence of the time intervals between PCI and surgery on the event time curve, data were separated into: time of PCI less than 35 days before surgery, between 35 and 90 days and longer than 90 (up to 365) days before surgery. Using 2-statistics, patients having had a recent PCI have more events than the calculated expected rate (numbers not shown).
The correlation of time from PCI to surgery and cumulative event rate can be seen by separating the initial overall event time curve of Figure 1A by the three levels of the category: time interval between PCI and surgery (<35, 35–90, >90 days). This is depicted in Figure 1B and clearly demonstrates that the greatest event rate exists in patients with recent stents (OR 2.11, 95% CI 1.11–4.33). All of these patients suffered a cardiac event within 600 days of surgery (Fig. 1B). Still a somewhat increased rate may exist in patients with PCI between 35 and 90 days before surgery (OR 1.3, 95% CI 0.53–3.06) compared with patients with PCI more than 90 days before surgery. The separation of the three event time curves occurs very early, indicating different risk a priori. Results from log rank tests confirmed the differences of the three event time curves (P<0.01).
Very similar results were obtained when the outcome was restricted to cardiac events (re-PCI, myocardial infarction and death), thus excluding the two patients with only bleeding events (Fig. 1C). The statistical difference between curves was again confirmed using log rank testing (P<0.01).
The second covariate identified was the heparin regimen chosen, a result reported with great caution and later discussed under the limitations of this study.
Using the multivariate approach provided by the Cox Proportional Hazards Model, only the categories of time interval from PCI to surgery (P<0.01) and the choice of heparins (P<0.01) were identified as influential cofactors in the event time analysis.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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Number of adverse events, type, severity and their time of occurrence in patients with recent stent placement were prospectively addressed in this study. The risk of adverse events remains high, with a mortality of approximately 5%. All severe events were of cardiac origin, while bleeding was of minor importance. Patients with very recent PCI (<35 days earlier) had a 2.1-fold risk of suffering an adverse event compared with those with PCI more than 90 days earlier.
The study results have to be interpreted knowing that the coronary arteries after PCI are still at risk.14 15 Non-cardiac surgery after PCI with stenting remains a delicate balance between the deleterious stent thrombosis with myocardial infarction, the potential risk of increased intra- and postoperative blood loss, hypercoagulability attributable to the surgical trauma16 and the perioperative stress. Hypocoagulability resulting from blood loss, haemodilution and hypothermia may also be important. Antiplatelet drugs are required and applied to prevent stent thrombosis and myocardial infarction, which now occur at a rate below 1% in the non-operative setting.17 This rate appears to be greater perioperatively. Therefore, our perioperative management was faced towards detection and rapid medical or interventional treatment of myocardial ischaemia, close monitoring in the immediate postoperative period and pharmacological protection against stent thrombosis.
In 1998, Tabuchi and colleagues18 reported a patient who underwent PCI with stenting 2 months and 1 week before surgery. The antiplatelet medications, aspirin and ticlopidin were discontinued before surgery. As it is known that stents are prone to rapid thrombosis and occlusion until they are endothelialized, the authors reported a detailed regimen of unfractionated heparin infusion perioperatively. Surgery and the postoperative course of the patient were uneventful. This report is to our best knowledge the only publication specifically reporting a modification of the antiplatelet/antithrombotic drug therapy after PCI for the perioperative period. It resembles the regimen generally applied in patients with prosthetic heart valves, when switching from warfarin therapy to heparin. Thus, this regimen represents one option for treatment.
The first report of adverse outcome was published by Kaluza and colleagues7 in the year 2000. They retrospectively evaluated 40 patients who underwent non-cardiac surgery after recent PCI with stent implantation, with a 20% perioperative mortality rate. Seven myocardial infarctions and 11 cases of severe bleeding were reported. The majority of events occurred in patients who underwent PCI very recently. The investigators did not control the intake or discontinuation of the antiplatelet medication, nor perioperative heparinization. Although our overall event rate of nearly 50% is similar to the study by Kaluza and colleagues, the spectrum and severity is different. Severe bleeding occurred in only two patients in this study and the cardiac mortality was below 5%. There are a number of possible reasons for this. Firstly, the reduced mortality may be attributed to our efforts to detect and treat myocardial ischaemia. Secondly, eight patients in this study underwent repeat PCI after surgery which may be a more effective treatment of ischaemia than that used in the study by Kalzula and colleagues. Thirdly, coronary stenting study in their study was even more proximate to non-cardiac surgery (39 days or less) than in our own study. We thus cannot endorse the recommendations of Kaluza and colleagues7 of delaying surgery for only 2–4 weeks in the light of the present results in which we observed a median delay of 60 days, in the group of patients,in which all suffered events.
In 2001, we published a case of PCI 33 days before urologic surgery.9 The antiplatelet therapy was discontinued 5 days before surgery and replaced by 0.5 mg kg–1 enoxaparin daily. Surgery was uneventful, but the patient suffered a severe myocardial infarction in the post-anaesthesia care unit because of stent thrombosis. CPR was successful, followed by emergency repeat PCI, but when aggressive antiplatelet therapy in conjunction with heparin was initiated during the second PCI, the patient suffered severe intestinal bleeding. We concluded that 0.5 mg kg–1 enoxaparin was not sufficient to prevent stent thrombosis and subsequent myocardial infarction.9 Since then, at least 1 mg kg–1 enoxaparin or the current regimen of unfractionated heparin is used in the study institutions. Our anti-thrombotic regimes were associated with two cases of bleeding and two additional cases of cardiac events plus bleeding. Blood loss was not the primary cause of mortality, rather it was secondary to cardiac events. We conclude that the above regimens cannot completely prevent cardiac or severe cardiac events but the immediate availability of a PCI may have helped to prevent a fatal outcome.
In 2003, Wilson and colleagues8 published a retrospective study of 207 patients from the preceding decade, who underwent surgery within 60 days after PCI and stent placement. Eight patients (4%) suffered severe cardiac events inclusive of six patients who died. Interestingly, all patients suffering these cardiac events had PCI 6 weeks or less before surgery, no event occurred in patients with stents older than 6 weeks. Two additional patients experienced severe bleeding. The authors recommended postponing non-cardiac surgery for 6 weeks based on the assumption that coronary stents are generally endothelialized and the course of antiplatelet therapy is completed.8 Our prospective study results are in good agreement with the retrospective investigation by Wilson and colleagues in terms of low early mortality rates, low and non-fatal bleeding rates and in the identification of recently stented patients as the patients with the greatest risk for subsequent cardiac events. Substantial differences exist with regard to the duration of the antiplatelet therapy. Wilson and colleagues8 suggest a rather brief combination therapy of two platelet inhibitors and a partial endothelialization of the stent as sufficient to prevent stent thrombosis. Perioperative heparinization is not specifically reported. In our study, it was generally recommended and agreed by the cardiology community to combine aspirin and clopidogrel or formerly ticlopidin for 1–3 months and then continue aspirin alone. During the course of this study, this recommendation was expanded to a 6–9 month combination therapy, which led us to the <35, 35–90 and >90 days categorization of stent age. The duration and combination of antiplatelet therapy appears to be of greater importance when drug-eluting stents are used, because they are apparently more prone to early thrombosis than bare metal stents.17 19–21 We furthermore emphasize that complete endothelialization of stents may occur within a few weeks, but this may also last longer than a year.22 The endothelialization process appears to be somewhat unpredictable in the individual patient, therefore, the individual risk may not be estimated without invasive investigation.
In 2004, Marcucci and colleagues23 presented a fatal case of stent thrombosis after lung surgery. The antiplatelet drugs were discontinued for 2 weeks. They concluded that prophylactic preoperative PCI puts the patient at risk of acute ischaemic events if surgery cannot be postponed for 3 months. Alternative strategies (ß-blockade) for preoperative cardiac management were suggested. In this study, ischaemic events occurred also after 90 days of PCI and despite ß-blocker intake.
In December 2004, McFalls and colleagues24 published a prospective study which investigated the potential benefit of prophylactic re-vascularization procedures (CABG or PCI) before elective vascular surgery. The stable and low risk patients included in their study were randomly assigned to medical therapy alone (n=252) or re-vascularization (n=258). The choice between PCI (n=141) and CABG surgery (n=99) was not randomized but determined in the light of the expected best treatment. The mortality rate reported was 22–23% after 2.7 yr of follow-up. Their study did not reveal any benefit attributable to CABG or PCI in comparison with optimized medical treatment of coronary artery disease before vascular surgery. Details of altered antithrombotic/antiplatelet medication were not reported by McFalls and colleagues. The study of McFalls and colleagues is in good agreement with our results; cardiac events are the major cause of morbidity and mortality after surgical interventions, even when patients undergo re-vascularization procedures before surgery. However, their mortality rate appears greater; a difference which could be attributed to their higher risk, major surgery (abdominal aortic aneurysms or arterial occlusive disease of the legs) compared with the mixed type of surgical cases included in this study.
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Study limitations |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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Although the present investigation is the largest prospective study of PCI in a mixed population of non-cardiac surgical interventions, the number of 103 patients is low when compared with the cardiological literature. Thus, not all covariates studied in addition to stent age may reach statistical significance. The choice of LMW vs unfractionated heparin was unequally distributed between patients with and without adverse events in the univariate test. This cofactor of heparin regimen was also identified as significant in the multivariate analysis using the Cox Proportional Hazards Model. We suggest extreme caution in interpreting the positive association between unfractionated heparin and postoperative cardiac events. The choice of heparin was not randomized, was unbalanced, was at the discretion of the attending physicians, and may therefore be heavily biased. Furthermore, this study was not intended to identify the best heparin regimen for the perioperative setting and was underpowered to address that question.
Another limitation is that the study population included a myriad of stent numbers, types, lengths and diameters. Included were bare metal types and some drug-eluting stents. This may influence our findings, because long and small, and drug-eluting stents may more likely result in early occlusion.17 19–21 25–29 Additionally, although all patients knew that they had PCI and stenting once, none knew the type, the exact location and other details. Stent identification cards do not exist. We were unable to exactly identify the stent characteristics in the majority of patients because of poor, incomplete or even missing documentation.
This study does not include patients with stents older than a year before surgery, because we did not want to confound our results by progressive in-stent restenoses attributable to intimal hyperplasia. The clear focus was on stent thrombosis which is more likely with recently implanted, not completely covered stents.
This study cannot answer the question if preoperative stenting decreases the risk as compared with standard, conservative therapy of coronary artery disease. Furthermore, it cannot answer directly if the risk in these patients is greater compared with patients without coronary artery disease undergoing similar procedures.
The indication for re-PCI was determined by the cardiologist on duty. Re-PCI was performed in only eight patients, in whom stent thrombosis was definitely the cause for myocardial infarction. We cannot distinguish between stent thrombosis, plaque rupture, progression of stenoses, in-stent restenosis or relative coronary insufficiency in the remaining 38 patients with cardiac events.
Finally, we have to consider additional biases. With all prospective, unblinded, observational studies, procedures, and materials change and evolve during the inclusion period, and the attention and care of the medical personnel may increase as preliminary results become apparent.
Based on the evidence of the recent literature30–34 and the current results, we summarize our findings as follows: first, new cardiac morbidity is the major threat to patients undergoing non-cardiac surgery after PCI with stent implantation. Second, cardiac events are most likely to occur in the early postoperative period and continue to occur on occasion until several years after surgery, although the mechanisms for these events may change over time. Therefore, heightened alertness, monitoring and postoperative stay in an ICU or IMC are justified. Rapid availability of a PCI unit appears life-saving in some cases and is therefore recommended. Third, increased blood loss and postoperative bleeding occur rarely and are not life-threatening, despite administration/continuation of anticoagulatory and antiplatelet drugs.
A benefit of scheduled PCI before intended non-cardiac surgery cannot directly be derived from this study. However, very recent PCI is associated with the greatest risk for cardiac and severe cardiac events. Owing to the lack of standardized, comparable and reliable laboratory tests, antiplatelet drug effects can still not be individually measured, titrated or antagonized during the perioperative period. Thus, more suitable alternatives to antiplatelet drugs may further be refined for the perioperative setting.
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Acknowledgments |
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Funding for this study was provided solely from departmental sources.
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Footnotes |
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Preliminary, short-term results from this study were presented at the ASA Annual Meeting 2003 in San Francisco, USA. 
This article is accompanied by the Editorial.
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References |
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TopAbstractIntroductionPatients and methodsResultsDiscussionStudy limitationsReferences |
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G. Godet, Y. Le Manach, F. Lesache, S. Perbet, and P. Coriat Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem? Br. J. Anaesth., April 1, 2008; 100(4): 472 - 477. [Abstract] [Full Text] [PDF]
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 C. Rao, R. D. L. Stanbridge, J. Chikwe, J. Pepper, P. Skapinakis, O. Aziz, A. Darzi, and T. Athanasiou Does Previous Percutaneous Coronary Stenting Compromise the Long-Term Efficacy of Subsequent Coronary Artery Bypass Surgery? A Microsimulation Study Ann. Thorac. Surg., February 1, 2008; 85(2): 501 - 507. [Abstract] [Full Text] [PDF]
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 L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery J. Am. Coll. Cardiol., October 23, 2007; 50(17): e159 - e242. [Full Text] [PDF]
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 S. Windecker and B. Meier Late Coronary Stent Thrombosis Circulation, October 23, 2007; 116(17): 1952 - 1965. [Full Text] [PDF]
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L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation, October 23, 2007; 116(17): e418 - e500. [Full Text] [PDF]
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J. W. Riddell, L. Chiche, B. Plaud, and M. Hamon Coronary Stents and Noncardiac Surgery Circulation, October 16, 2007; 116(16): e378 - e382. [Full Text] [PDF]
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P.-G. Chassot, A. Delabays, and D. R. Spahn Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction Br. J. Anaesth., September 1, 2007; 99(3): 316 - 328. [Abstract] [Full Text] [PDF]
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 S. L. Cohn and G. W. Smetana Update in Perioperative Medicine Ann Intern Med, August 21, 2007; 147(4): 263 - 270. [Full Text] [PDF]
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 M. Thielmann, M. Neuhauser, S. Knipp, E. Kottenberg-Assenmacher, A. Marr, N. Pizanis, M. Hartmann, M. Kamler, P. Massoudy, and H. Jakob Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 470 - 476. [Abstract] [Full Text] [PDF]
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D. W. Harrington and M. T. Munekata Update in General Internal Medicine Ann Intern Med, July 17, 2007; 147(2): 104 - 116. [Full Text] [PDF]
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E. S. Brilakis, S. Banerjee, and P. B. Berger Perioperative Management of Patients With Coronary Stents J. Am. Coll. Cardiol., June 5, 2007; 49(22): 2145 - 2150. [Abstract] [Full Text] [PDF]
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G. M. Howard-Alpe, J. de Bono, L. Hudsmith, W. P. Orr, P. Foex, and J. W. Sear Coronary artery stents and non-cardiac surgery Br. J. Anaesth., May 1, 2007; 98(5): 560 - 574. [Abstract] [Full Text] [PDF]
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P. Albaladejo, E. Marret, V. Piriou, and C.-M. Samama Perioperative management of antiplatelet agents in patients with coronary stents: recommendations of a French Task Force. Br. J. Anaesth., October 1, 2006; 97(4): 580 - 582. [Full Text] [PDF]
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H. Dent, Z. Lekic, and M. Vicenzi Unfractionated heparin and coronary artery stenting. Br. J. Anaesth., October 1, 2006; 97(4): 582 - 582. [Full Text] [PDF]
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D. R. Spahn, S. J. Howell, A. Delabays, and P.-G. Chassot Coronary stents and perioperative anti-platelet regimen: dilemma of bleeding and stent thrombosis. Br. J. Anaesth., June 1, 2006; 96(6): 675 - 677. [Full Text] [PDF]
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E-letters:
Read all E-letters
- Unfractionated heparin and coronary artery stenting
- Howard Dent, et al.
- British Journal of Anaesthesia, 27 Jun 2006 [Full text]
- Re: Unfractionated heparin and coronary artery stenting
- Martin N Vicenzi
- British Journal of Anaesthesia, 13 Jul 2006 [Full text]
- Patient and stent characteristics may important for antiplatelet therapy discontinuation
- Ashish Aneja
- British Journal of Anaesthesia, 8 Aug 2006 [Full text]
- Risk of surgery after coronary stent replacement
- Emmanouil S. Brilakis
- British Journal of Anaesthesia, 8 Aug 2006 [Full text]
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