If patient just had an event, when might surgery proceed afterwards?
ACC presents data on the rates of reinfarction postoperatively for patients with an MI before noncardiac surgery. The reinfarction rate is quite high when surgery occurs within the first 30 days after MI, and that rate steadily falls as one’s surgery is weeks and months farther out from an MI. Thus ACC suggests that it would be advisable to delay surgery at least 60 days after an MI.
The ACC guideline reviews evidence on whether CABG prior to another planned surgery confers any benefits at all (not much literature, seems no benefit, but benefit may exist for subgroups yet to be determined). No guidelines reviewed, however, specifically addresses optimal recovery time after CABG before another non-emergent surgery.
Angioplasty without stenting:
– elective non-cardiac surgery should be delayed 14 days from balloon angioplasty (ACC I, C)
–
elective non-cardiac surgery should not be performed within 14 days of
balloon angioplasty in patients in whom aspirin will need to be
discontinued perioperatively (ACC III:H, B)
Angioplasty with bare metal stent
- elective non-cardiac surgery should be delayed 30 days from bare metal stent (BMS) placement (ACC I, B)
-
elective non-cardiac surgery should not be performed within 30 days
after BMS in patients in whom dual antiplatelet therapy (DAPT) will need
to be discontinued perioperatively (ACC III:H, B)
- for stented
patients who must undergo a surgery which mandates discontinuation of
P2Y12-inhibitor (clopidogrel and similar) therapy, continue aspirin if
possible and restart the P2Y12-inhibitor as soon as possible after
surgery. (ACC I, C)
- when surgery is required, consensus decision
among treating clinicians on relative risks of surgery and use/disuse
of antiplatelet therapy can be useful (ACC IIa, C)
- ACC algorithm summary post-BMS:
<30 days: try to delay surgery
>30 days: proceed to surgery
Angioplasty with drug eluting stent:
- elective non-cardiac surgery should optimally be delayed 6 months from drug eluting stent (DES) placement (ACC I, B)
-
elective non-cardiac surgery after DES may be considered after 3 months
if the risk of further delay is greater than the expected risks of
ischemia and stent thrombosis (ACC IIb, B)
- elective non-cardiac
surgery should not be performed within 3 months after DES in patients in
whom dual antiplatelet therapy (DAPT) will need to be discontinued
perioperatively (ACC III, B)
- for stented patients who must
undergo a surgery which mandates discontinuation of P2Y12-inhibitor
(clopidogrel and similar) therapy, continue aspirin if possible and
restart the P2Y12-inhibitor as soon as possible after surgery. (ACC I,
C)
- when surgery is required, consensus decision among treating
clinicians on relative risks of surgery and use/disuse of antiplatelet
therapy can be useful (ACC IIa, C)
- ACC algorithm summary post-DES:
<3 mos: try to delay surgery
3-6 mos: depends on urgency of surgery
>6 mos: proceed to surgery
- elective non-cardiac non-neurologic surgery should be delayed at least 6 months and preferably 9 months from time of incident stroke (AHA-ASA '21)
AHA-ASA scientific statement notes that two studies show elevated risk of subsequet stroke which peaks under 3 months out from stroke and levels out to lower levels after 6 and further after 12 months out from stroke. Thus they recommend delaying elective surgery 6-9 months after stroke.
The latest evidence (JAMA Surg '22) looked at more than 5 million patients 66 and older between 2011 and 2018 from the US Medicare, 54,033 of whom had a previous stroke. They found that risk of stroke recurrence and mortality were both greatest within 30 days after surgery. But after 30 days, stroke recurrence and mortality fell off quickly to much lower levels and did not statistically differ at 61 to 90 days postop compared to intervals farther out from surgery such as 181 to 360 days or > 360 days. Their conclusion is that the AHA-ASA scientific statement above may be excessively long and should be reconsidered.