Graham Laura A, Maddox Thomas M, Itani Kamal M F, Hawn Mary T
Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL, USA.
Am Surg. 2013 May;79(5):514-23.
Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.
对于需要后续手术的心脏支架置入患者，抗血小板治疗的管理较为复杂。当前指南建议推迟择期手术，或者如果手术紧急，则在不停用阿司匹林的情况下进行手术。本研究评估了医疗服务提供者对需要后续手术的心脏支架置入患者的知识、态度和实践情况。对退伍军人事务部的外科医生、麻醉师和心脏病专家进行了一项全国性调查。问题涉及指南意识和认同度、对出血风险和支架血栓形成的看法、抗血小板治疗管理的实践模式以及围手术期支架血栓形成的经验。采用卡方检验和广义估计方程来检验报告实践中的差异。在295名受访者中，指南意识（92%）和认同度（93%）较高，但心脏病专家和麻醉师的指南意识和认同度高于外科医生。指南认同度和支架血栓形成的个人经验也与报告的实践模式相关。在早期手术的校正模型中，无论支架类型如何（药物洗脱支架P = 0.03；裸金属支架P < 0.01），与外科医生相比，心脏病专家和麻醉师更有可能报告继续双重治疗。尽管成功采用了指南，但发现不同医疗服务提供者类型的实践模式存在显著差异。了解这些差异背后的原因以及各种抗血小板管理策略的结果，是优化接受非心脏手术的冠状动脉支架置入患者护理的重要步骤。
