The prevalence of ischemic heart disease in surgery patients is increasing. Up to 34 % of patients require surgery within one year of percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy (DAPT) should be introduced for at least 12 months to prevent late stent thrombosis, especially in drug-eluting stents (DES), where endothelisation of stented segment is slower. Risk of stent thrombosis is greater with recent myocardial infarction, bifurcation lesions, suboptimal stent deployment, first generation DES, while second generation DES and bare metal stents have lower risk of stent thrombosis. Although some randomized studies showed that it might be safe do discontinue DAPT 3-6 months after second generation DES implantation, stent thrombosis is still feared and grave complication in first year after PCI. The preoperative management of patients after PCI requires consideration of bleeding risk on DAPT and risk of stent thrombosis. There are no randomized data about optimal timing of surgery. Guidelines recommend postponing surgery for at least 6 months after percutaneous coronary intervention with drug-eluting stent implantation (DES-PCI) and 12 months if PCI was done following myocardial infarction. The 2016 American College of Cardiology/American Heart Association guidelines update strongly advises against elective noncardiac surgery <3 months after DES implantation, but surgery may be considered 3 to 6 months after DES-PCI, with discontinuation of DAPT if the delayed surgery risk is greater than the stent thrombosis risk. A big recent Danish study showed that surgery in first 12 months after DES-PCI was associated with an increased risk of myocardial infarction and cardiac death but not all-cause mortality compared to patients without ischemic heart disease. However, the increased risk was only present within first month after DES-PCI. According to PARIS registry it may be safe to interrupt DAPT for <14 days under physician guidance. Knowing both, surgery might be undertaken earlier than currently recommended. There is a consensus that excluding emergency, surgery can be done between 1 and 3 months after DES-PCI if there is uncontrolled bleeding or the outcome is strongly influenced by surgical delay. On the other hand, surgery should be delayed at least 3 to 6 months in acute coronary syndrome, diabetes mellitus, low left ventricular ejection fraction, history of stent thrombosis, PCI of left main, small stents and long stented segments.
Keywords: percutaneous coronary intervention, surgery, antiplatelet therapy.
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