Coronary artery stents and non-cardiac surgery
Cardiff, UK
E-mail: sheshagiribengeri{at}gmail.com
I read the article by Howard-Alpe and colleagues1 with great interest. The authors say ‘their management should involve careful discussion between the surgeons, anaesthetists, cardiologists, and haematologists’. I think we are forgetting the most important person—the patient. We always discuss with the patient before we start any treatment advantages, disadvantages, and complications. We should in my opinion discuss with the patient before stopping any treatment, especially before having an operation. Recently, I had a patient who was treated with clopidogrel for stroke prevention. Initially, she preferred an epidural analgesia for her postoperative pain relief. When she realized that she cannot have her clopidogrel until the epidural catheter was removed, she chose not to have the epidural. In my opinion, if given a choice, the patients would prefer to have slightly more blood loss over having another MI or stroke. The anaesthetists should continue to play the vital role, but also document patient's wishes.
Oxford, UK
E-mail: georgina.howard-alpe{at}nda.ox.ac.uk
Editor—We read with interest the comments of Dr Bengeri, in response to our recent review article on the perioperative management of patients with coronary artery stents undergoing non-cardiac surgery.1 We agree with Dr Bengeri that the patient is indeed the most important person in the equation and it is our desire to ensure the provision of the best information and clinical care to the patient through the education of those involved in their management that led us to write this review article. Our survey in the Oxford region revealed the lack of knowledge and level of confusion that exists about the perioperative management of patients with coronary artery stents undergoing non-cardiac surgery,2 and the lack of formal guidelines only exacerbates this problem.
Treatment options should always be discussed with the patient concerned and they should be made aware of the potential risks and benefits of different management strategies. However, we would encourage a universal clear message from all members of the team responsible for the patient's care and this requires discussion and communication between all involved; anaesthetist, cardiologist, surgeon, and haematologist, as recommended in the article. This approach relies on all members of the team being educated and informed about the issues and potential risks involved.
We emphasize as stressed in the review, each patient must be considered on an individual basis as both the risk and consequences of surgical bleeding and stent thrombosis will vary. Equally, the potential benefits of regional anaesthesia will vary according to the type of surgery and the individual patient's co-morbidity. As with many issues in medicine, it is our job as professionals to weigh up the consequences of the different options available and present information to the patient in a balanced, unbiased manner, advising them of the consensus of medical opinion regarding the safest management plan. This allows the patient to make a truly informed decision. To do this, we have a responsibility to gain an excellent understanding of the various risks involved and to be speaking with one voice.
References
1 Howard-Alpe GM, De Bono J, Hudsmith L, Orr WP, Sear JW, Foex P. Coronary artery stents and non-cardiac surgery. Br J Anaesth (2007) 98:560–74.
2 Hudsmith L, De Bono J, McKenna C, Foex P, Orr WP. Dual antiplatelet therapy and non-cardiac surgery risk; what are the anaesthetists and surgeons doing? Eur Heart J (2006) 27:380–1.
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