Association Between Antifibrinolytic Therapy and Perioperative Outcomes in Patients With Coronary Artery Stents Undergoing Noncardiac Surgery.
Aged
Aged, 80 and over
Antifibrinolytic Agents
/ administration & dosage
Cohort Studies
Female
Humans
Male
Middle Aged
Orthopedic Procedures
/ adverse effects
Percutaneous Coronary Intervention
/ adverse effects
Perioperative Care
/ adverse effects
Postoperative Complications
/ diagnosis
Retrospective Studies
Risk Factors
Stents
/ adverse effects
Journal
Anesthesia and analgesia
ISSN: 1526-7598
Titre abrégé: Anesth Analg
Pays: United States
ID NLM: 1310650
Informations de publication
Date de publication:
01 06 2021
01 06 2021
Historique:
pubmed:
30
3
2021
medline:
28
7
2021
entrez:
29
3
2021
Statut:
ppublish
Résumé
Patients with existing coronary artery stents are at an increased risk for major adverse cardiac events (MACEs) when undergoing noncardiac surgery (NCS). Although the use of antifibrinolytic (AF) therapy in NCS has significantly increased in the past decade, the relationship between perioperative AF use and its association with MACEs among patients with existing coronary artery stents has yet to be assessed. In this study, we aim to evaluate the association of MACEs in patients with existing coronary artery stents who receive perioperative AF therapy during orthopedic surgery. A single-center retrospective cohort study was conducted in adult patients with existing coronary artery stents who underwent orthopedic surgery from 2008 to 2018. Two cohorts were established: patients with existing coronary artery stents who did not receive perioperative AF and patients with coronary artery stents who received perioperative AF. Associations between AF use and the primary outcome of MACEs within 30 days postoperatively and the secondary outcomes of thrombotic complications, excessive surgical bleeding, and intensive care unit (ICU) admissions were analyzed using logistic regression models. Inverse probability of treatment weighting was used to control for confounding. Secondary analyses examining the association between coronary stent type/timing and the outcomes of interest were performed using unadjusted logistic regression models. A total of 473 patients met study criteria, including 294 who did not receive AF and 179 patients who received AF. MACEs occurred in 15 (5.1%) patients who did not receive AF and 1 (0.6%) who received AF (P = .007). In weighted analyses, no significant difference was found in patients who received AF with regard to MACEs (odds ratio [OR] = 0.13, 95% confidence interval [CI], 0.01-1.74, P = .12), thrombotic complications (OR = 1.19, 95% CI, 0.53-2.68, P = .68), or excessive surgical bleeding (OR = 0.13, 95% CI, 0.01-2.23, P = .16) compared to patients who did not receive AF. The results of this study are inconclusive whether an association exists between perioperative AF use in patients with coronary artery stents and the outcome of MACEs compared to patients who did not receive perioperative AF therapy. The authors acknowledge that the imprecise CI hinders the ability to definitively determine whether an association exists in the study population. Further large prospective studies, powered to detect differences in MACEs, are needed to assess the safety of perioperative AF in patients with existing coronary artery stents and to clarify the mechanism of perioperative MACEs in this high-risk population.
Sections du résumé
BACKGROUND
Patients with existing coronary artery stents are at an increased risk for major adverse cardiac events (MACEs) when undergoing noncardiac surgery (NCS). Although the use of antifibrinolytic (AF) therapy in NCS has significantly increased in the past decade, the relationship between perioperative AF use and its association with MACEs among patients with existing coronary artery stents has yet to be assessed. In this study, we aim to evaluate the association of MACEs in patients with existing coronary artery stents who receive perioperative AF therapy during orthopedic surgery.
METHODS
A single-center retrospective cohort study was conducted in adult patients with existing coronary artery stents who underwent orthopedic surgery from 2008 to 2018. Two cohorts were established: patients with existing coronary artery stents who did not receive perioperative AF and patients with coronary artery stents who received perioperative AF. Associations between AF use and the primary outcome of MACEs within 30 days postoperatively and the secondary outcomes of thrombotic complications, excessive surgical bleeding, and intensive care unit (ICU) admissions were analyzed using logistic regression models. Inverse probability of treatment weighting was used to control for confounding. Secondary analyses examining the association between coronary stent type/timing and the outcomes of interest were performed using unadjusted logistic regression models.
RESULTS
A total of 473 patients met study criteria, including 294 who did not receive AF and 179 patients who received AF. MACEs occurred in 15 (5.1%) patients who did not receive AF and 1 (0.6%) who received AF (P = .007). In weighted analyses, no significant difference was found in patients who received AF with regard to MACEs (odds ratio [OR] = 0.13, 95% confidence interval [CI], 0.01-1.74, P = .12), thrombotic complications (OR = 1.19, 95% CI, 0.53-2.68, P = .68), or excessive surgical bleeding (OR = 0.13, 95% CI, 0.01-2.23, P = .16) compared to patients who did not receive AF.
CONCLUSIONS
The results of this study are inconclusive whether an association exists between perioperative AF use in patients with coronary artery stents and the outcome of MACEs compared to patients who did not receive perioperative AF therapy. The authors acknowledge that the imprecise CI hinders the ability to definitively determine whether an association exists in the study population. Further large prospective studies, powered to detect differences in MACEs, are needed to assess the safety of perioperative AF in patients with existing coronary artery stents and to clarify the mechanism of perioperative MACEs in this high-risk population.
Identifiants
pubmed: 33780399
doi: 10.1213/ANE.0000000000005522
pii: 00000539-202106000-00018
pmc: PMC8154652
mid: NIHMS1673603
doi:
Substances chimiques
Antifibrinolytic Agents
0
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
1635-1644Subventions
Organisme : NCATS NIH HHS
ID : UL1 TR002377
Pays : United States
Informations de copyright
Copyright © 2021 International Anesthesia Research Society.
Déclaration de conflit d'intérêts
The authors declare no conflicts of interest.
Références
Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462–1472.
Smith BB, Warner MA, Warner NS, et al. Cardiac risk of noncardiac surgery after percutaneous coronary intervention with second-generation drug-eluting stents. Anesth Analg. 2019;128:621–628.
Albaladejo P, Marret E, Samama CM, et al. Non-cardiac surgery in patients with coronary stents: the RECO study. Heart. 2011;97:1566–1572.
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016;134:e123–e155.
Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025–2035.
Shakur H, Roberts I, Bautista R, et al.; CRASH-2 trial collaboratorsEffects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23–32.
Shakur H, Roberts I, Fawole BEffect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389:2105–2116.
Alshryda S, Sarda P, Sukeik M, et al. Tranexamic acid in total knee replacement. J Bone Joint Surg Br. 2011;93:1577–1585.
CRASH-3 trial collaboratorsEffects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. 2019;394:1713–1723.
Ping WD, Zhao QM, Sun HF, Lu HS, Li F. Role of tranexamic acid in nasal surgery: a systemic review and meta-analysis of randomized control trial. Medicine (Baltimore). 2019;98:e15202.
Mina SH, Garcia-Perdomo HA. Effectiveness of tranexamic acid for decreasing bleeding in prostate surgery: a systematic review and meta-analysis. Cent European J Urol. 2018;71:72–77.
Winter SF, Santaguida C, Wong J, Fehlings MG. Systemic and topical use of tranexamic acid in spinal surgery: a systematic review. Global Spine J. 2016;6:284–295.
Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ. 2012;344:e3054.
Kaptein YE. Acute ST-elevation myocardial infarction due to in-stent thrombosis after administering tranexamic acid in a high cardiac risk patient. BMJ Case Rep. 2019;12:e227957.
Garg J, Pinnamaneni S, Aronow WS, Ahmad H. ST elevation myocardial infarction after tranexamic acid: first reported case in the United States. Am J Ther. 2014;21:e221–e224.
Turgeon RD, Koshman SL, Youngson E, et al. Association of ticagrelor vs clopidogrel with major adverse coronary events in patients with acute coronary syndrome undergoing percutaneous coronary intervention. JAMA Intern Med. 2020;180:420–428.
Chute CG, Beck SA, Fisk TB, Mohr DN. The enterprise data trust at mayo clinic: a semantically integrated warehouse of biomedical data. J Am Med Inform Assoc. 2010;17:131–135.
Singh B, Singh A, Ahmed A, et al. Derivation and validation of automated electronic search strategies to extract Charlson comorbidities from electronic medical records. Mayo Clin Proc. 2012;87:817–824.
Schulman S, Angerås U, Bergqvist D, Eriksson B, Lassen MR, Fisher W; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost. 2010;8:202–204.
Thygesen K, Alpert JS, Jaffe AS, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018;72:2231–2264.
McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, Ramchand R, Burgette LF. A tutorial on propensity score estimation for multiple treatments using generalized boosted models. Stat Med. 2013;32:3388–3414.
Painter TW, McIlroy D, Myles PS, Leslie K. A survey of anaesthetists’ use of tranexamic acid in noncardiac surgery. Anaesth Intensive Care. 2019;47:76–84.
Bridges KH, Wilson SH. Acute coronary artery thrombus after tranexamic acid during total shoulder arthroplasty in a patient with coronary stents: a case report. A A Pract. 2018;10:212–214.
Devereaux PJ, Eikelboom J. Insights into myocardial infarction after noncardiac surgery in patients with a prior coronary artery stent. Br J Anaesth. 2016;116:584–586.
Wąsowicz M, Syed S, Wijeysundera DN, et al. Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study. Br J Anaesth. 2016;116:493–500.
Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic therapy and perioperative considerations. Anesthesiology. 2018;128:657–670.
Henry DA, Carless PA, Moxey AJAnti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2011:CD001886.
Howell SJ, Hoeks SE, West RM, Wheatcroft SB, Hoeft A; OBTAIN Investigators of European Society of Anaesthesiology (ESA) Clinical Trial Network. Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery. Br J Anaesth. 2019;122:170–179.
Benenati S, Galli M, De Marzo V, et al. Very short vs. Long dual antiplatelet therapy after second generation drug-eluting stents in 35,785 patients undergoing percutaneous coronary interventions: a meta-analysis of randomised controlled trials. Eur Heart J Cardiovasc Pharmacother. 2021;7:86–93.
Cho S, Kim JS, Kang TS, et al. Long-term efficacy of extended dual antiplatelet therapy after left main coronary artery bifurcation stenting. Am J Cardiol. 2020;125:320–327.
Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology. 2008;109:588–595.
Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology. 2008;109:596–604.
Devereaux PJ, Xavier D, Pogue J, et al.; POISE (PeriOperative ISchemic Evaluation) Investigators. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154:523–528.
Madhavan MV, Kirtane AJ, Redfors B, et al. Stent-related adverse events >1 year after percutaneous coronary intervention. J Am Coll Cardiol. 2020;75:590–604.