Registry Data Confirm Increase in Bleeding with Noncardiac Surgery After PCI vs CABG

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Noncardiac surgery carries similar ischemic risk for patients who have recently undergone revascularization irrespective of whether they received percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery, reports a Japanese registry study published online July 29, 2014, ahead of print in Circulation: Cardiovascular Interventions. However, bleeding complications are far more common among patients with prior PCI. 

The difference in bleeding risk may stem from greater use of dual antiplatelet therapy among PCI patients, Takeshi Kimura, MD, of Kyoto University (Kyoto, Japan), and colleagues note. 

In the 3 years following revascularization, noncardiac surgery was performed in a greater proportion of CABG patients compared with PCI patients (27% vs 22%; P < .0001). The difference reached statistical significance within the first 6 months (P < .0001) but not thereafter (P = .04). Adjusting for baseline differences, CABG continued to be associated with greater incidence of noncardiac surgery vs PCI (HR 1.15; 95% CI 1.03-1.29; P = .02). 

Surgeries tended to occur earlier after CABG than after PCI, and dual vs single antiplatelet therapy was more common in PCI patients. A trend was seen toward greater use of general/spinal anesthesia in procedures following CABG (table 1). 

Table 1. Characteristics of Noncardiac Surgery

At 30 days, the risk of ischemic events (death/MI) was similar for both cohorts, while bleeding events (GUSTO moderate/severe) trended higher in PCI patients. With adjustment, the difference in bleeding became significant (P = .02; table 2).

Table 2. Thirty-Day Outcomes: Crude Rates and Adjusted Risk

Most ischemic events were death, with similar rates of overall and cardiac death seen in the CABG and PCI groups. However, half of the 41 cardiac deaths occurring in PCI patients were related to complications of MI that occurred before noncardiac surgery. 

There were no interactions between the timing of noncardiac surgery and the types of revascularization for either ischemic or bleeding outcomes. 

Better PCI Antiplatelet Regimen Might Minimize Postsurgical Bleeding  

Dr. Kimura and colleagues could not distinguish between noncardiac surgery that was already scheduled at the time of revascularization and procedures whose need only became evident at a later date. 

“Nevertheless,” the authors say, “it seems plausible that patients scheduled for surgical procedures after coronary revascularization were more likely to undergo CABG rather than PCI, because early surgical procedures after coronary stent implantation, DES in particular, were reported to be associated with prohibitive risk for both ischemic and bleeding complications.” 

The researchers propose that perioperative dual antiplatelet therapy in PCI patients is responsible for the increased bleeding after noncardiac surgery. If true, there is room to improve practice, they suggest.

“Perioperative bleeding complications could be reduced with more appropriate perioperative management of [antiplatelet therapy],” they conclude. “Therefore, both PCI and CABG could be viable options in patients who are scheduled for noncardiac surgery after coronary revascularization.”

Source: 
Tokushige A, Shiomi H, Morimoto T, et al. Incidence and outcome of surgical procedures after coronary artery bypass grafting compared with those after percutaneous coronary intervention. Circ Cardiovasc Interv. 2014; Epub ahead of print. 

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