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  • Review Article
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Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management

Nature Reviews Cardiology volume 18, pages 37–57 (2021)Cite this article

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Abstract

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5–25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.

Key points

  • Numerous prothrombotic, inflammatory and haemodynamic stressors related to surgery can exacerbate the risk of myocardial ischaemia in patients with underlying coronary artery disease (CAD).

  • Preoperative cardiac risk assessment and perioperative monitoring of patients with CAD are essential to optimize risk reduction strategies and improve surgical outcomes.

  • A multidisciplinary approach involving all perioperative care specialists is necessary to define the various aspects of surgical risk.

  • Patients undergoing non-cardiac surgery after recent coronary stent placement have higher rates of adverse cardiac events; however, guidelines lack specific recommendations for the optimal perioperative management of this subgroup.

  • Decisions regarding antiplatelet therapy during non-cardiac surgery must be made with the goal of achieving a balance between the potential benefit of preventing thrombotic events and avoiding bleeding complications.

  • Bridging with intravenous antiplatelet agents is a viable strategy for patients on dual antiplatelet therapy undergoing non-deferrable surgery, but still needs to be validated in a randomized clinical study.

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Fig. 1: Pathogenesis of perioperative myocardial ischaemia in patients with CAD.
Fig. 2: Preoperative cardiac risk assessment in patients undergoing non-cardiac surgery.
Fig. 3: Guideline-recommended timing of non-cardiac surgery in patients on DAPT with a coronary stent.
Fig. 4: Proposed algorithm for perioperative management of antiplatelet therapy in patients with CAD referred for non-cardiac surgery.
Fig. 5: Perioperative bridging protocols in patients on DAPT undergoing non-cardiac surgery.

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Authors and Affiliations

  1. The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Davide Cao, Rishi Chandiramani & Roxana Mehran

  2. Division of Cardiology, C.A.S.T., P.O. “G. Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy

    Davide Capodanno

  3. Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA

    Jeffrey S. Berger

  4. Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Matthew A. Levin

  5. Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA

    Mary T. Hawn

  6. Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA

    Dominick J. Angiolillo

Authors
  1. Davide Cao
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  2. Rishi Chandiramani
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  3. Davide Capodanno
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  4. Jeffrey S. Berger
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  5. Matthew A. Levin
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  6. Mary T. Hawn
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  7. Dominick J. Angiolillo
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  8. Roxana Mehran
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Contributions

D.Cao, R.C. and R.M. researched data for the article. All authors contributed to discussion of content, wrote the article and reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Roxana Mehran.

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Competing interests

D.Capodanno has received consulting fees or honoraria from Amgen, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Daiichi Sankyo and Sanofi. D.J.A. has received grant support, consulting fees and honoraria from Abbott, Amgen, Aralez, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi Sankyo, Eli Lilly, Janssen, Merck and Sanofi; consulting fees and honoraria from Haemonetics, the Medicines Company, PhaseBio, PLx Pharma and Pfizer; grant support and fees for review activities from CeloNova; fees for review activities from St Jude Medical; and grant support from CSL Behring, Eisai, Gilead, Idorsia Pharmaceuticals, Matsutani Chemical Industry, Novartis, Osprey Medical, RenalGuard Solutions and the Scott R. MacKenzie Foundation. R.M. has received institutional grants from Abbott, AstraZeneca, Bayer, Beth Israel Deaconess, Bristol Myers Squibb, Chiesi, Concept Medical, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals, OrbusNeich; has received personal fees from Abbott, Boston Scientific, Janssen Scientific Affairs, Medscape, Medtelligence (Janssen Scientific Affairs), Roivant Sciences, Sanofi and Siemens Medical Solutions; has received consultant fees paid to the institution from Abbott and Bristol Myers Squibb; has received advisory board funding paid to the institution from Spectranetics/Philips/Volcano Corp; has <1% equity in Claret Medical and Elixir Medical; has received Data and Safety Monitoring Board Membership fees paid to the institution from Watermark Research Partners; has been a consultant (no fee) for Idorsia Pharmaceuticals and Regeneron Pharmaceuticals; and her spouse has received consultant fees from Abiomed and The Medicines Company. All other authors declare no competing interests.

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Nature Reviews Cardiology thanks J.-P. Collet, J. Douketis, K. Eagle and L. Fleisher for their contribution to the peer review of this work.

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Cao, D., Chandiramani, R., Capodanno, D. et al. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 18, 37–57 (2021). https://doi.org/10.1038/s41569-020-0410-z

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