Valle Javier A, Graham Laura, DeRussy Aerin, Itani Kamal, Hawn Mary T, Maddox Thomas M
VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO, USA.
Division of Cardiology, University of Colorado Hospital, 12631 E. 17th Street, B130, Aurora, CO, 80045, USA.
World J Surg. 2017 Feb;41(2):423-432. doi: 10.1007/s00268-016-3725-5.
Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown.
We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics.
Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients.
One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.
三联疗法，即抗凝剂与双联抗血小板治疗（DAPT）联合使用，常用于对有抗凝指征的经皮冠状动脉介入治疗（PCI）术后患者预防缺血事件，但会增加出血风险。由于围手术期缺血和出血风险均增加，三联疗法对接受手术患者的影响可能尤为显著。目前该人群的预后尚不清楚。
我们确定了2004年至2012年在退伍军人事务医院PCI术后2年内接受非心脏手术的患者。我们比较了接受三联疗法和DAPT的患者在手术期间的主要不良心血管和脑血管事件（MACCE：死亡率、心肌梗死、中风、血运重建）和出血事件（住院出血、输血），并对临床、人口统计学和手术特征进行了调整。
在7811例手术中，391例（5.0%）发生在接受三联疗法的患者中。三联疗法患者手术时发生44例（11.3%）MACCE和107例（27.4%）出血事件，而DAPT患者分别为366例（4.9%）MACCE和980例（13.2%）出血事件。调整后，与DAPT患者的手术相比，三联疗法患者的手术发生MACCE的几率更高[比值比（OR）1.65，95%置信区间（CI）1.16 - 2.34]或出血几率更高（OR 1.52，95% CI 1.17 - 1.99）。
每20例接受非心脏手术的PCI术后患者中有1例接受三联疗法。与接受DAPT的患者相比，这些患者的手术发生MACCE和出血事件的几率更高，且与临床和手术特征无关。这些发现确定了一个手术高危人群，可能需要加强对围手术期不良事件的监测。
