Significant differences between vascular and nonvascular surgeons in the perioperative management of antiplatelet therapies in patients with coronary stents

Medical therapy for atherosclerotic cardiovascular disease in patients with myocardial injury after non-cardiac surgery

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States.

METHODS

Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients.

RESULTS

A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS.

CONCLUSIONS

The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.

Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery

STUDY OBJECTIVE

Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery.

DESIGN/SETTING/PATIENTS

We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period).

MEASUREMENTS

Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets.

MAIN RESULTS

A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period.

CONCLUSIONS

In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.