From The Geelong Hospital.
Correspondence to: Stephen N. Bolsin, MBBS, The Geelong Hospital, Anaesthetics, Ryrie St, Geelong, VIC, Australia 3220; e-mail: firstname.lastname@example.org
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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We were intrigued to read the article by Darvish-Kazem et al1 published in CHEST (December 2013) regarding guidelines for the perioperative management of patients with implanted coronary artery stents requiring noncardiac surgery. The review of the guidelines appears to have included some studies that identified an increased risk of major adverse cardiac events at the time of noncardiac surgery, but no studies reporting a decreased incidence of bleeding and stent thrombosis.2-4 The Geelong Hospital group first reported the successful use of tirofiban and heparin “bridging” therapy for patients with implanted drug-eluting stents (DESs).2 Since then, 71 cases of successful perioperative DES management have been described in the literature, including the tirofiban bridging therapy described by the Conroy et al3 and Savonitto et al4 groups. Including our unreported but recorded experience, > 100 patients with DESs and at risk of major adverse cardiac events or perioperative bleeding have successfully received tirofiban or tirofiban and heparin bridging therapy for urgent noncardiac surgery.5
The early success of The Geelong Hospital tirofiban and heparin bridging therapy allowed one of our group to recommend this treatment to the Australian and New Zealand Cardiac Society Guideline Writing Committee, of which he was a member.6 Thus, despite the lack of uniform international guidelines on this specific topic, there is considerable documented experience in the management of these devices in Australia and Italy that has contributed to national guidelines in Australia and New Zealand. We hope that perioperative stent thrombosis may now be a diminishing problem as the risk/benefit assessment of bare-metal stents and DESs, along with the newer generations of percutaneous coronary artery stents, is reevaluated in elderly patients.5
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