October 9, 2013
News Review From Harvard Medical School -- Surgery after Stent? Assessing the Risk
A new study offers guidance for people who need non-heart surgery soon after having a stent placed to open a clogged artery. Researchers wanted to find out what medical situations increase the risk of heart-related problems within 30 days of the surgery. The study looked at data on about 28,000 people who had stent procedures. Each person also had non-heart surgery in the 2 years after the stent was placed. About 5% died or had a major heart problem within a month after that surgery. The problems included a heart attack or the need for another procedure to open an artery. These heart problems were more likely among people who had their surgery within 6 weeks to 6 months after the stent was placed. Problems also occurred more often in 3 groups. They included people who had their surgery on an emergency basis, those who had a heart attack less than 6 months before surgery and those who had high scores on a risk scale. The risk scores were based on people's medical history, blood tests and the risk level of their specific surgery. The Journal of the American Medical Association published the study. HealthDay News wrote about it October 7.
By Reena L. Pande, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
We all understand that having surgery always carries some risk. For minor surgeries, that may simply be the discomfort of going through the procedure. For others, there may be a risk of bleeding or a risk of infection.
But for people with known heart disease, having unrelated surgery can carry an added risk of heart troubles. These can include having a heart attack, congestive heart failure or other complications. The risk increases when patients have had recent heart problems, such as a heart attack, angioplasty or stenting (procedures to open up a blocked blood vessel in the heart).
When to proceed with surgery in patients like these is the source of much debate in the medical community. On the one hand, doctors hate to delay needed surgery. On the other hand, we want to make sure that we can get you through whatever surgery you need without any major problems. Sometimes it's a delicate balance of risks and benefits.
A study published this week sheds some light on the risks of having non-cardiac surgery in patients with known heart disease. Non-cardiac surgery includes any surgery not involving the heart. Examples include hip replacement, colon surgery or brain surgery.
The researchers looked at more than 40,000 operations in patients who had a heart stent placed in the last 2 years. Then they asked what factors seemed linked to an increased risk of heart complications after non-cardiac surgery. These complications included:
- Heart attack
- Death for any reason
- Need to have a heart procedure to restore blood flow to a blocked artery
The risk of complications was greater when the surgery happened less than 6 months after a heart stent was placed. The very highest risk arose when the surgery was less than 6 weeks after stent placement.
The researchers also found the highest risk of a heart problem after surgery in the following situations:
- The surgery was an emergency.
- The patient had a heart attack less than 6 months before the surgery.
- The patient had a higher "risk score." The scores take into account whether someone has had a prior stroke, heart disease, kidney disease or diabetes. Scores also were higher for people who had a higher-risk surgery.
What Changes Can I Make Now?
It can be very hard to figure out what you as a patient can do to increase the chance that your surgery will be problem-free. But there are some things you should think about when considering surgery.
- How urgent is the surgery? Your doctor will help you figure this out. Sometimes it's an absolute emergency, a life-or-death situation. In this case, the risk of dying is so great that nothing should stand in the way of the surgery. But when it's less clear, take the time to have an open discussion with your doctor. Discuss whether you need the surgery and whether you need it now. It may be worth waiting a few extra months for that knee replacement if it means a lower risk of having any heart complications.
- Should I stop my heart medicines or stay on them? Please clarify this with your doctors. The answer is not always clear. For many procedures, you will have to stop certain medicines. But some surgeries can be done while continuing heart medicines, such as aspirin. It's always better to ask than to assume you should stop them.
- Do I need any other heart tests? Often you will be asked to have an electrocardiogram. This test involves putting many stickers on your chest to check your heart rhythm. In some cases, you may be asked to have a stress test. But people who are at a lower risk of heart problems during surgery may not need any special heart testing. You probably are at lower risk if you are in good physical condition and can do a decent amount of physical activity. An example would be climbing a few flights of stairs without chest pain or breathing problems.
What Can I Expect Looking to the Future?
More and more patients with heart disease are getting non-heart surgeries. Doctors and patients need to understand better what puts these patients at risk of heart complications from surgery. This knowledge will be key in making informed decisions about whether to have surgery and the timing of surgery. In the end, we need to weigh both the risks and the benefits before deciding what to do.