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The authors’ reply:
  1. M J Luckie,
  2. R S Khattar,
  3. D G W Fraser
  1. Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK
  1. Correspondence to Dr D G W Fraser, Manchester Heart Centre Oxford Road Manchester M13 9WL, UK; doug.fraser{at}cmmc.nhs.uk

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We thank Drs Carmignani and Picozzi for their comment on our article1 and for providing an insight into their experience of newly diagnosed neoplastic disorders requiring surgery after coronary stenting.2 We agree that with rising rates of coronary stent implantation, the need for unexpected non-cardiac surgery during dual antiplatelet therapy following stenting will be an increasing problem in the future. The diagnosis of any concealed condition requiring non-cardiac surgery may allow operative intervention to be undertaken before stent implantation, provided that the risk of potential perioperative cardiac complications is not excessive. Screening programmes exist in the UK for cervical, breast and colonic cancer, as well as a “risk management programme” for prostate cancer, and a screening programme for abdominal aortic aneurysm due to start in 2009. We agree that clinicians should aim to ensure that appropriate screening is up-to-date before elective coronary intervention, in order to minimise the chance of interrupting dual antiplatelet therapy for future unexpected non-cardiac surgery. However, routine abdominal ultrasonography before coronary stent implantation is unlikely to prove cost effective because the detection of disease will be small. Ultrasonography could perhaps be combined with testing for microscopic haematuria, and targeted towards those at particular risk of these diseases. The efficacy and cost effectiveness of this strategy would need to be demonstrated in a randomised controlled trial in the first instance. In addition, in cases requiring urgent coronary intervention, proper preassessment may not be practical and decisions about the interventional procedure—in particular, stent type, must be made based on available information.

Future advances in coronary stent technology may render this less of a problem. The continuing development of bioabsorbable stents, and endothelial progenitor cell capture stents may limit the need for prolonged duration of dual antiplatelet therapy. These stents have been shown to be safe with dual antiplatelet therapy prescribed for only 4 weeks in the case of endothelial progenitor cell stents,3 and 2–3 months for bioabsorbable stents.4 5 However, while conventional drug-eluting stents remain the mainstay of coronary intervention, clinicians should remain vigilant about the potential need for future surgery and manage each patient on an individual basis when this problem arises.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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