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Bare Metal Stents Are Better for Some Heart Patients, Jefferson Scientists Find

Patients with non-cardiac surgery imminently scheduled should avoid drug-eluting stents

While drug-eluting stents are effective in keeping open diseased heart arteries, they should not be used for patients who need to have non-cardiac surgery a short time after an interventional heart procedure. A presentation at the Society for Cardiovascular Angiography and Interventions in Orlando by cardiologists at Jefferson Medical College of Thomas Jefferson University in Philadelphia indicates that for these patients, bare metal stents provide a safer alternative.

“Patients who receive drug-eluting stents, which are coated with a medicine to help prevent arteries from re-closing, may develop life-threatening cardiac complications if they undergo subsequent, non-cardiac surgery,” says Michael Savage, MD, Director of the Cardiac Catheterization Laboratory at Thomas Jefferson University Hospital.

Applies to all types of surgeries
This potentially deadly problem begins when a patient plans on having non-cardiac surgery. It doesn’t matter what type of surgery – orthopedic, colorectal, urological, vascular, neurological, etc., or if the surgery is vital or elective.   

What does matter is if coronary artery disease is discovered during the pre-surgical testing. If severe, the detected coronary disease presents a more-immediate problem and therefore, must be treated before the patient undergoes the non-cardiac surgery.

“Part of the risk of having any type of surgery and anesthesia is the stress that is created on the cardiovascular system that may cause blood clotting and result in cardiac instability following the surgery,” Dr. Savage notes. “Because of that, it’s very common for patients who are middle-aged or older to undergo a pre-operative examination to make sure their cardiovascular status is stable enough to have the surgery without danger of subsequent cardiac complications.

“The stress test may reveal signs of a blocked coronary artery,” he continues. “Those patients with low-risk abnormalities may be kept stabilized with medical therapy. But those that have major ischemia [a low oxygen state due generally to obstructed or otherwise inadequate blood flow] will undergo an interventional heart procedure – a cardiac catheterization procedure or angioplasty [widening of an artery narrowed by fatty deposits by inserting into it a catheter with a tiny balloon that is then inflated], culminating in the placement of a stent to prevent subsequent restenosis [re-narrowing of the newly opened artery].”

Safety treatment strategy
Prior studies have shown that patients may suffer fatal heart attacks due to clotting inside of the stents when non-cardiac surgery is performed within a few weeks after stent placement. When drug-eluting stents are used, clotting may occur months or even years after their heart procedure, particularly when patients’ blood-thinning medicines (usually aspirin and Plavix) are stopped before the surgery.

To avoid this potentially deadly scenario, the Jefferson researchers developed a clinical protocol to enable patients to have both the preliminary cardiac procedure and then the non-cardiac procedure successfully with little risk. Led by Agostino Ingraldi, MD, a fellow in Interventional Cardiology, they developed the following four-part strategy:

• Avoidance of drug-eluting stents in favor of bare metal stents during the interventional heart procedure
• A four-week course of the blood thinner clopidogrel (Plavix) for the patient after stent placement
• Deferral of the second, non-cardiac surgery for five to 12 weeks after the interventional heart procedure
• Discontinuation of clopidogrel (Plavix) at least five days prior to the non-cardiac surgery
  

The researchers studied 60 patients (33 men and 27 women) whose average age was 68 years old. Twenty seven percent suffered from diabetes, which can complicate surgery. All were treated with the aforementioned strategy.

The results show the coronary interventional procedure was successful in all patients (a total of 82 heart lesions were treated with bare-metal stents in this group of 60 patients).  The second, non-cardiac, surgery was performed an average of 47 days later; all of these non-cardiac surgeries were performed under general anesthesia and were also successful, with no deaths or clotting of the coronary stents.

“This research provides a safe treatment strategy for patients who will be undergoing further surgery,” adds Dr. Savage, who is also Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University. “Drug-eluting stents are still a wonderful technology in the right patients; they have proven benefits but may not be the best solution for every patient – certainly not for patients who plan to have non-cardiac surgery within a year of having a stent implanted, or those who have bleeding problems and cannot take blood-thinning medicines for an extended period of time.”

Coronary angiograms (x-rays) performed in a 75-year-old woman undergoing multi-vessel angioplasty prior to successful orthopedic surgery:

Figure 1: two blockages (indicated by arrows) in the left anterior descending coronary artery

Figure 2: the result after placement of two bare-metal stents

Figure 3: diffuse disease with blockages of the right coronary artery

Figure 4: the excellent result after placement of two bare-metal stents