Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
The Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham Veterans Administration Hospital, Birmingham, Alabama.
J Am Coll Cardiol. 2014 Dec 30;64(25):2730-9. doi: 10.1016/j.jacc.2014.09.072.
Recent coronary stent placement and noncardiac surgery contribute to the risk of adverse cardiac events, but the relative contributions of these two factors have not been quantified.
This research was designed to determine the incremental risk of noncardiac surgery on myocardial infarction (MI) and coronary revascularization following coronary stenting.
A U.S. retrospective cohort study of patients receiving coronary stents at Veterans Affairs medical centers between 2000 and 2010 was used to match patients undergoing noncardiac surgery within 24 months of stent placement to two patients with stents not undergoing surgery. Patients were matched on stent type and cardiac risk factors present at the time of stent placement. A composite endpoint of MI and/or cardiac revascularization for the 30-day interval post-surgery was calculated. Adjusted risk differences (RD) were compared across time periods following stent implantation, using generalized estimating equations.
We matched 20,590 surgical patients to 41,180 nonsurgical patients. During the 30-day interval following noncardiac surgery, the surgical cohort had higher rates of the composite cardiac endpoint (3.1% vs. 1.9%; RD: 1.3%; 95% confidence interval: 1.0% to 1.5%). The incremental risk of noncardiac surgery adjusted for surgical characteristics ranged from 3.5% immediately following stent implantation to 1% at 6 months, after which it remained stable out to 24 months. Factors associated with a significant reduction in risk following surgery more than 6 months post-stent included elective inpatient procedures (ΔRD: 1.8%; p = 0.01), high-risk surgery (ΔRD: 3.7%; p = 0.01), and drug-eluting stent (DES) (ΔRD: 1.3%; p = 0.01).
The incremental risk of noncardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilizes at 1.0% after 6 months. Elective, high-risk, inpatient surgery, and patients with DES may benefit most from delay from a 6-month delay after stent placement.
近期冠状动脉支架置入术和非心脏手术增加了不良心脏事件的风险，但这两个因素的相对贡献尚未量化。
本研究旨在确定冠状动脉支架置入术后非心脏手术对心肌梗死（MI）和冠状动脉血运重建的增量风险。
使用美国退伍军人事务部医疗中心 2000 年至 2010 年期间接受冠状动脉支架置入术的患者的回顾性队列研究，将在支架置入后 24 个月内行非心脏手术的患者与未行手术的 2 名支架置入患者相匹配。患者按照支架类型和支架置入时存在的心脏危险因素进行匹配。计算术后 30 天内 MI 和/或冠状动脉血运重建的复合终点。使用广义估计方程比较支架置入后不同时间的调整风险差异（RD）。
我们将 20590 例手术患者与 41180 例非手术患者相匹配。在非心脏手术后 30 天内，手术组的复合心脏终点发生率较高（3.1% vs. 1.9%；RD：1.3%；95%置信区间：1.0%至 1.5%）。调整手术特征后的非心脏手术增量风险范围从支架置入后即刻的 3.5%到 6 个月时的 1%，此后至 24 个月时保持稳定。术后 6 个月以上手术风险显著降低的因素包括择期住院手术（ΔRD：1.8%；p=0.01）、高危手术（ΔRD：3.7%；p=0.01）和药物洗脱支架（DES）（ΔRD：1.3%；p=0.01）。
支架置入后患者非心脏手术对不良心脏事件的增量风险在支架置入后最初 6 个月内最高，6 个月后稳定在 1.0%。择期、高危、住院手术和接受 DES 的患者可能从支架置入后 6 个月的延迟中获益最大。
