A point-of-care troponin I level was elevated at 1. The patient was treated with clopidogrel mg and a heparin infusion. The left coronary system had mild luminal irregularities only.
The question of the appropriate management of an acute coronary syndrome in the context of an urgent, but not emergent, non-cardiac surgery is a complex one and requires an individualized approach. To make an informed decision, however, it is crucial to understand all of the options available and their future impact on perioperative management.
Pursuing medical management alone has the benefit of obviating the risk of a stent thrombosis during perioperative discontinuation of antiplatelet therapy. However, with high-risk GRACE and TIMI risk scores and ongoing chest pain, the patient in the vignette would be at substantial risk for early morbidity and mortality in the acute setting. Additionally, unlike patients with stable ischemic heart disease, early revascularization in patients with an acute coronary syndrome has been shown to reduce the risk of death or reinfarction.
Coronary artery bypass grafting may have the benefit of providing full revascularization without the need for long-term dual antiplatelet therapy DAPT but involves the early hazard of a major surgery. In our patient's case in particular, performing bypass surgery for single-vessel non-left anterior descending artery or left main disease has not been shown to have a long-term benefit on mortality and indeed may be associated with upfront harm. As a general rule, DES placement maintains the benefits of BMS over balloon angioplasty in terms of preventing acute vessel recoil and dissection while addressing the shortfalls of BMS, specifically the risk of target-lesion revascularization due to restenosis from neointimal tissue growth.
However, current stent designs have undergone significant changes. The second-generation DES have thinner struts and thinner and more biocompatible polymer, both of which reduce the risk of restenosis and stent thrombosis.https://demetperspass.tk
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Moreover, the fluoropolymer on the everolimus-eluting stent has been shown to be thromboresistant. As such, in a meta-analysis including over , patient-years of follow-up, cobalt-chromium everolimus-eluting DES had significantly lower rates of not only target-vessel revascularization but also MI, stent thrombosis, and even death than BMS.
However, these data may not be directly applicable to the patient discontinuing DAPT but continuing aspirin monotherapy earlier than the recommended duration. In a propensity-matched analysis of patients undergoing non-cardiac surgery less than 1 year after coronary stent placement 6, of whom underwent first-generation DES placement and 1, of whom underwent BMS placement , there were significantly fewer instances of death or MI in the DES group at 30 days post-surgery compared with the BMS group odds ratio 0.
There is now a randomized trial that has compared the outcomes of DES versus BMS in high-risk patients, including those undergoing non-cardiac surgery.
The investigators found that the primary endpoint a composite of death, MI, or target-vessel revascularization was significantly lower in the DES group than the BMS group hazard ratio 0. The patient in the vignette underwent uncomplicated placement of three cobalt-chromium everolimus-eluting DES in the proximal-to-mid-right coronary artery and was discharged in stable condition on DAPT.
Three months later, he underwent uncomplicated curative radical prostatectomy with temporary discontinuation of his clopidogrel while continuing aspirin through the perioperative period. He continues to follow up in the outpatient setting. Figure 1. The correct answer is: C. SlideShare Explore Search You.
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