ISCHAEMIC HEART DISEASE

Late risks of using drug eluting coronary stents ▸

Although good at reducing restenosis, drug eluting stents (DES) have not yet been shown to reduce mortality. There is a known risk to performing non-cardiac surgery soon after bare metal stenting, presumably from stent thrombosis when endothelialisation has not occurred. However, operations done after six weeks appear to be safe even when antiplatelet agents are stopped. The same may not be true for DES. Four case reports are presented with clopidogrel having been stopped safely six months after DES. However, with the aspirin being stopped > 30 days after the first procedure in preparation for non-cardiac surgery, 4–5 days later, in-stent thrombosis of the DES occurred. The cause is not clear, but presumably poor endothelialisation may play a part. Plan—keep the aspirin going if at all possible.

Can PCI be safely performed in institutions without cardiac surgery facilities available onsite? ▸

A retrospective study using Medicare data aimed to answer this question by analysing patient outcomes over a two year period from 178 hospitals without and 943 hospitals with onsite surgery. An overall analysis found that patients undergoing percutaneous coronary intervention (PCI) in hospitals without surgical facilities were more likely to die within 30 days of the procedure (6.0% v 3.3%), but the authors uncovered some interesting findings after accounting for baseline differences. While mortality for primary/rescue PCI was similar in hospitals regardless of whether cardiac surgery was available or not (adjusted odds ratio (OR) 0.93, 95% confidence interval (CI) 0.80 to 1.08; p  =  0.34), mortality for patients in the non-primary/rescue PCI population was significantly higher in the hospitals without onsite surgery (adjusted OR 1.38, 95% CI 1.14 to 1.67; p  =  0.01). Noticeably, this increase in mortality was confined to hospitals performing 50 or fewer Medicare PCIs a year. However, can this difference be explained purely by lack of readily available cardiac surgery alone? The authors themselves admit this is not …