If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery
- Gilles Godet (28 May 2008)
-
Drug-eluting stent thrombosis and non-cardiac surgery
- Deepak K. Tempe (16 May 2008)
-
Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem?
- Gilles Godet (23 April 2008)
-
Drug Eluting Stents and non-cardiac surgery: endpoints and stent thrombosis
- Harish Ramakrishna MD, FASE (13 April 2008)
|
|
|||
|
Gilles Godet
Send letter to journal:
|
We would like to thank Dr Tempe for its interest in our paper. As it appears in our article (see Table 1), the mean delay between DES insertion and date for non-cardiac surgery is 14 months. However, both SD (11 months) and range (1 week-36 months) show that the ideal one-year duration for clopidogrel treatment was not always attained in our series of patients. In fact, clopidogrel was discontinued mainly because the need for surgery, unplanned at the time of coronary revascularization (it is more difficult to predict the future than the past!). In contrast to the more dogmatic AHA-ACC guidelines, a short discontinuation of clopidogrel was decided on by the anesthetists and surgeons of our team, with the advice of a cardiologist, in relation to the relative risks for i: in-stent thrombosis (IST), and ii: increased bleeding. As a result, we did not observed an increased risk of bleeding in our patients (bleeding is a well-known factor for postoperative cardiac complication in such patients). Concerning our attitude for management of antiplatelet agents, the low incidence of IST in this series does not allow us to demonstrate a strong relation between IST on the one hand, and both delay between DES insertion and surgery, or discontinuation of antiplatelet agents, on the other . Conflict of Interest:None declared |
|||
|
|
|||
|
Deepak K. Tempe
Send letter to journal:
|
I read with great interest the recently published article by Godet and colleagues on drug eluting stent (DES) thrombosis.(1) Recent literature indicates that barring neurosurgery, the risk of bleeding is small (if the antiplatelet medicines are continued), but the risk of acute coronary event due to stent thrombosis is high (if the antiplatelet medicines are discontinued); the risk of the cardiac event being greater in patients with recent stents.(2,3) The results of Godet’s study suggest that the risk of specific thrombotic complications of DES is uncommon, despite discontinuing the antiplatelet medicines. However, careful analysis of the results reveals that the delay between DES and surgery was 14 months. The details of this delay are not provided, specifically in patients in whom the antiplatelet medicines were discontinued and those who suffered complications. The latest American College of Cardiology (ACC) / American Heart Association (AHA) guidelines recommend that all elective surgeries should be postponed till 1 year after DES implantation.(4) Recent data also indicate that clopidogrel should be continued for one year after all types of DES, despite the increased risk of bleeding.(5) This indirectly implies that clopidogrel may be discontinued for non-cardiac surgery after one year of placement. Thus, if the interval between the DES implantation and the non-cardiac surgery is ≥12 months, Godet and colleagues are actually following the ACC / AHA guidelines and discontinuation of clopidogrel is permissible. In this scenario, the results would confirm the correctness of the guidelines. Therefore, the details of the interval between DES implantation and the non-cardiac surgery in this study become important and should be provided. Further, the results also confirm that the risk of bleeding is indeed low, because only 3 patients undergoing carotid endarterectomy developed moderate haematoma. Dr. Deepak K. Tempe Director-Professor and Head Department of Anaesthesiology and Intensive Care G.B. Pant Hospital (University of Delhi) New Delhi. tempedeepak@hotmail.com References: 1. Godet G, Le Manach Y, Lesache F, Perbet S, Coriat P. Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem? Br J Anaesth 2008;100:472-7 2.Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery—a prospective outcome study. Br J Anaesth 2006;96:686-93 3.Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy:the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007;99:316-28 4.Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. ACC / AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology / American Heart Associatioin Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2007;116:1971-1996 5.Hodgson JM, Stone GW, Lincoff AM, Klein L, et al. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from Society for Cardiovascular Angiography and Interventions Drug- eluting Stent Task Force. Catheter Cardiovasc Interven 2007;69:327-33 Conflict of Interest:None declared |
|||
|
|
|||
|
Gilles Godet
Send letter to journal:
|
I would like to thank Dr Ramakrishna for its interest in our article and the interesting points which he raise. Drug-eluting stents (DES) obviously carry more risks than bare-metal stents (BMS). Because all experts recommend avoiding premature discontinuation of antiplatelet agents therapy (AA) if possible (the patients must remain on dual antiplatelet agents medication for a minimum of 6 or 12 months after insertion), and requires postponing elective surgery for one year. In contrast, when an invasive procedure is required, the risk of intrastent thrombosis (IST) arises after stopping AA and a risk of bleeding if treatment is continued. The French cardiology community is not as divided as in the US. Related to the “not so unsafe” characteristics of DES, there is strong agreement for restricted use of them. The latter are indicated in the most severely ill patients ie, patients with anatomically challenging lesions such as long, thin vessels, bifurcation lesions and chronic total occlusions, patients with diabetes, and patients without the need for further non cardiac surgery. We agree that troponin elevation is not uncommon in severe CAD patients, and is unlikely related to IST. It is evidence that the ECG remains the gold standard for diagnosis of IST. Finally, we agree with Dr Ramakrishna: anaesthetists must keep up to date with the rapidly evolving world of cardiology to ensure a safe anesthetic care of these patients. Conflict of Interest:None declared |
|||
|
|
|||
|
Harish Ramakrishna MD, FASE, Anesthesiologist Mayo Clinic
Send letter to journal:
|
Editor, I read with interest the paper by Drs Godet et al and they raise several important issues relating to drug eluting stents perioperatively which seem to be getting more confusing and contradictory with each passing study. The cardiology community in the United States is divided as to how to interpret the latest data which seem to indicate that drug eluting stents may not be as unsafe as labelled. However, a growing body of literature suggests that there is an increasing trend toward the implantation of bare metal stents in complicated patients (diabetes, acute coronary syndromes, renal failure,veingrafts, multiple and overlapping lesions) where the revascularization benefit with drug eluting stents is arguably reduced.(Ref 1- Tung R, Ann Int Med 2006, 114:913-919),as also in patients who will need imminent non cardiac surgery, those in whom dual anitplatelet therapy with aspirin and a thienopyridine is either not possible or practical. The middle of the road approach seems to be the selective use of drug eluting stents in patients who are at high risk for restenosis( less than 20% of patients)and bail out use in those who present with clinical restenosis after bare metal stent use(less than 10- 15% of patients) Ref 2:Moses JW, NEJM 2003; 349: 1315-23. I would also argue that post operative troponin release after vascular surgery is not uncommon and in no way should be a surrogate marker for stent thrombosis in the absence of clinical symptoms, angiographic endpoints should be the gold standard. Finally, in the absence of definitive data from randomized trials and conflicting studies that appear on a daily basis, it is of utmost importance to the anesthesiologist to keep up to date with the rapidly evolving world of invasive cardiology and maintain an ongoing dialogue with our colleagues in the catheterization suite to ensure the safe anesthetic care of these complex patients. Conflict of Interest:None declared |
|||