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Drug-Eluting Stents and Noncardiac SurgeryDrug-Eluting Stents and Noncardiac Surgery FREE TO VIEW

Stephen N. Bolsin, MBBS; Jessica Gillett, MBBS
Author and Funding Information

From The Geelong Hospital.

Correspondence to: Stephen N. Bolsin, MBBS, The Geelong Hospital, Anaesthetics, Ryrie St, Geelong, VIC, Australia 3220; e-mail: steveb@barwonhealth.org.au


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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1174. doi:10.1378/chest.14-0012
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To the Editor:

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

References

Darvish-Kazem S, Gandhi M, Marcucci M, Douketis JD. Perioperative management of antiplatelet therapy in patients with a coronary stent who need noncardiac surgery: a systematic review of clinical practice guidelines. Chest. 2013;144(6):1848-1856. [CrossRef] [PubMed]
 
Broad L, Lee T, Conroy M, et al. Successful management of patients with a drug-eluting coronary stent presenting for elective, non-cardiac surgery. Br J Anaesth. 2007;98(1):19-22. [CrossRef] [PubMed]
 
Conroy M, Bolsin SN, Black SA, Orford N. Perioperative complications in patients with drug-eluting stents: a three-year audit at Geelong Hospital. Anaesth Intensive Care. 2007;35(6):939-944. [PubMed]
 
Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285-291. [CrossRef] [PubMed]
 
Bolsin SN, Chin H, Birdsey G, Colson M, Gillet J. Coronary artery stents and surgery; the basis of sound perioperative management. Health. 2013;5(10):1730-1736. [CrossRef]
 
Cardiac Society of Australia and New Zealand. Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery. Heart Lung Circ. 2010;19(1):2-10. [CrossRef] [PubMed]
 

Figures

Tables

References

Darvish-Kazem S, Gandhi M, Marcucci M, Douketis JD. Perioperative management of antiplatelet therapy in patients with a coronary stent who need noncardiac surgery: a systematic review of clinical practice guidelines. Chest. 2013;144(6):1848-1856. [CrossRef] [PubMed]
 
Broad L, Lee T, Conroy M, et al. Successful management of patients with a drug-eluting coronary stent presenting for elective, non-cardiac surgery. Br J Anaesth. 2007;98(1):19-22. [CrossRef] [PubMed]
 
Conroy M, Bolsin SN, Black SA, Orford N. Perioperative complications in patients with drug-eluting stents: a three-year audit at Geelong Hospital. Anaesth Intensive Care. 2007;35(6):939-944. [PubMed]
 
Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285-291. [CrossRef] [PubMed]
 
Bolsin SN, Chin H, Birdsey G, Colson M, Gillet J. Coronary artery stents and surgery; the basis of sound perioperative management. Health. 2013;5(10):1730-1736. [CrossRef]
 
Cardiac Society of Australia and New Zealand. Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery. Heart Lung Circ. 2010;19(1):2-10. [CrossRef] [PubMed]
 
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