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decrease coronary restenosis and abrupt vessel closure as compared to standard coronary balloon angioplasty.1–4 Consequently, they are implanted in most patients requiring percutaneous coronary intervention (PCI).5 One major consideration with coronary stents is their thrombogenicity at the blood-tissue interface which may cause local thrombosis or distal coronary embolization. Those complications are associated with a 50% incidence of acute myocardial infarction (MI) and a 20% mortality rate,6 making prevention of stent thrombosis mandatory in all cases. The most effective antithrombotic strategy involves the administration of aspirin and a thienopyridine (clopidogrel or ticlopidine) for a minimum period of four to six weeks for bare metal stents and several months for drug-eluting stents, until significant re-endothelialization of the stent has occurred. With this approach, stent thrombosis within 30 days of implantation occurs in less than 1% of patients who had an uncomplicated PCI.6 The perioperative management of a patient with recent coronary stent implantation represents an obvious challenge. On the one hand, the continuation of the combined antiplatelet therapy during the perioperative period may cause major bleeding; on the other, its early cessation may lead to coronary thrombosis, a complication enhanced by the procoagulatory effect of surgery. In their most recent guideline update for perioperative cardiovascular evaluation for noncardiac surgery, the American College of Cardiology (ACC) and the American Heart Association (AHA) recommended a delay of at least two weeks and ideally four to six weeks between stent implantation and noncardiac surgery (e.g., four full weeks of dual antiplatelet therapy during stent re-endothelialization and two weeks for the antiplatelet effect to wear off).7 There is no prospective controlled trial to support that recommendation. However, at least two retrospective studies provide convincing arguments for its rationale.8,9 In the first study, of 40 patients undergoing noncardiac surgery less than six weeks after coronary stenting, seven (18%) had an MI, 11 (28%) had major bleeding and eight (20%) died.8 All deaths and MIs, and eight of the 11 bleeding episodes occurred in patients who had surgery less than two weeks after coronary stenting. In the second study, eight (4.0%) of 207 patients who had surgery within two months of coronary stenting suffered an MI, of whom six (2.9%) died.9 All deaths and MIs occurred among the 168 patients who had surgery within six weeks of stent placement. No major adverse event occurred in the 39 patients operated seven to nine weeks after stent placement. Those two studies did not determine whether the acute ischemic complications were due to coronary stenting or to the increased inflammatory and procoagulable state of those patients and the presence of other vulnerable plaques. In addition, they did not test whether postponing of surgery could improve outcome or not. However, they clearly indicate that noncardiac surgery within six weeks of coronary stenting is associated with an increased risk of serious perioperative cardiac events. Considering the potential risk of noncardiac surgery shortly after coronary stenting, one may assume that most Canadian anesthesiologists are familiar with the ACC/AHA guidelines for management of this condition. However, the survey conducted by Patterson et al. and published in this issue of the Canadian Journal of Anesthesia suggests that this may not be true.10 Of the 996 anesthesiologists who responded to the questionnaire, 63% were unaware of any published guidelines on this topic. Despite this lack of knowledge, 56% of the anesthesiologists 356 EDITORIAL

Noncardiac surgery in patients with coronary artery stent: what should the anesthesiologist know?