Risks of Non-Cardiac Surgery Early after Percutaneous Coronary Intervention

Abstract

Background:

Prior registry data suggest that 4–20% of patients require non-cardiac surgery (NCS) within 2 years of percutaneous coronary intervention (PCI). Contemporary data on NCS after PCI in the United States among women and men are limited. We determined the rate of early hospital readmission for NCS and associated outcomes in a large cohort of patients who underwent PCI in the United States.

Methods:

Adults undergoing PCI between January 1^st and June 30^th, 2014 were identified from the Nationwide Readmission Database. Patients readmitted for NCS within 6 months of PCI were identified. Outcomes of interest were in-hospital death, myocardial infarction (MI), and bleeding defined by ICD-9 codes.

Results:

Among 221,379 patients who underwent PCI and survived to hospital discharge, 3.5% (n=7,696) were readmitted for NCS within 6 months post-PCI, and 41% of these hospitalizations were elective. Early NCS was complicated by MI in 4.7% of cases, and 21% of perioperative MI were fatal. Bleeding was recorded in 32.0% of patients. All-cause mortality occurred in 4.4% of patients (n=339) readmitted for surgery. The risk of death or MI was greatest when NCS was performed within the first month after PCI.

Conclusions:

Despite clear guidelines to avoid surgery early after PCI, NCS was performed in 1 of every 29 patients with recent PCI, corresponding to as many as ~30,000 patients each year nationwide. Surgical mortality and perioperative MI was high in this setting. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.

Introduction:

Percutaneous coronary intervention (PCI) is routinely performed for stable ischemic heart disease and acute coronary syndromes in the United States. Older registry data suggest that up to 7.5% of patients require surgery in the first 6 months following PCI, and up to 20% of undergo surgery within 2 years.^1–6 Patients who require non-cardiac surgery (NCS) early after PCI are at increased risk of perioperative events compared with those without coronary stents.^6–11 This increased risk is likely due to differences in baseline cardiovascular comorbidities and burden of coronary artery disease, early discontinuation of antiplatelet therapy during the perioperative period, and the pro-thrombotic risks of recent stents and NCS.¹² As a consequence, clinical practice guidelines recommend avoiding surgery in the first 6 to 12 months after PCI with drug eluting stents (DES) and the first 4–6 weeks after PCI with bare metal stents (BMS), unless the benefits of early surgery outweigh the associated perioperative cardiovascular risks.^13–15 However, contemporary studies reporting the frequency and outcomes of surgery after PCI are largely based on European cohorts; studies from the United States have been either single-center,⁶ included mostly men,¹¹ or were conducted in the era of first generation drug eluting stents and largely prior to a major revision in perioperative care guidelines.^{11, 13} In the present study we sought to investigate the frequency and timing of in-hospital NCS within 6 months after PCI in a broadly representative nationwide cohort of patients in the United States in the contemporary era of second-generation drug eluting stents. In the same cohort, we also determined the incidence of in-hospital complications associated with surgery early after PCI.

Methods:

Study Population

Adults ≥18 years old admitted for PCI between January 1^st and June 30^th, 2014 were identified from the United States (US) Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project’s (HCUP) Nationwide Readmission Database (NRD), a national administrative database of hospital discharge-level data. The most recent year of data from the NRD includes 22 states and represents 51.2% of the US population and 49.3% of all US hospitalizations.¹⁶ Diagnosis of PCI was identified based on primary or non-primary International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9) procedure codes (ICD-9 procedure codes 36.01, 36.02, 36.05, 36.06, 36.07, 36.09, 17.55, and 00.66). Patients with acute myocardial infarction (MI) were identified using ICD-9 diagnosis codes for acute ST-segment elevation myocardial infarction (STEMI) (ICD-9 diagnosis codes 410.01 to 410.61, 410.81, and 410.91) and non-ST-segment elevation myocardial infarction (NSTEMI) (ICD-9 diagnosis code 410.71).¹⁷ Coronary stent type was determined by ICD-9 procedure codes. Among patients with >1 admission for PCI during the calendar year, the most recent PCI admission prior to hospitalization for NCS was included in the analysis. Among patients with multiple PCI who did not undergo NCS during the study period, only the first hospitalization for PCI during the calendar year was included in the analysis. Demographics and clinical comorbidities were defined by relevant ICD-9 diagnosis codes and AHRQ Elixhauser comorbidities for all patients.

Study Outcome

The primary study outcome was hospital readmission for NCS within 6-months, determined based on methodology described by HCUP.¹⁸ Hospitalizations for non-cardiac surgery were identified by the presence of any International Classification of Diseases, Ninth Revision (ICD-9) procedure code for a major therapeutic operating room procedure (HCUP Procedure Class 4) during the admission, as previously described.¹⁷ Clinical Classifications Software (CCS) procedure codes, AHRQ-defined groups of related ICD-9 procedure codes, were used to cluster hospitalizations by surgical subtype. Hospital admissions for general abdominal surgery, genitourinary surgery, neurosurgery, orthopedic surgery, otolaryngology, skin and breast surgery, thoracic surgery, vascular surgery, and other NCS not classified elsewhere were included in the readmission analysis.¹⁹ Hospital admissions with a principal CCS procedure code for cardiac procedures or surgery were excluded from the readmission analysis. Among patients with multiple readmissions for surgery within 6 months of the index hospital discharge after PCI, only the first readmission was included for analysis. Patients who underwent PCI in July through December were not included in the analysis due to incomplete 6 month follow-up data on readmissions.¹⁸ Outcomes of interest during hospital readmission for NCS were all-cause mortality, acute MI, and bleeding. Patients with documented bleeding and bleeding requiring intervention were identified by the relevant ICD-9 diagnosis and procedure codes, as previously described (Supplementary Appendix).^{20, 21} Red blood cell transfusions were identified from the ICD-9 procedure codes (ICD-9 procedure codes 99.01–99.04).

Statistical Analysis

Categorical variables were reported as percentages and were compared by χ-square tests. Continuous variables were reported as means with the standard error of measurement (SEM) and were compared using linear regression. Multivariable logistic regression models were generated to estimate odds ratios adjusted for patient demographics, cardiovascular risk factors, and comorbidities. Models included age, sex, obesity, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, end stage renal disease, prior revascularization with either PCI or CABG, peripheral vascular disease, congestive heart failure, valvular heart disease, prior venous thromboembolism, atrial fibrillation, malignancy, and anemia as covariates for adjustment. We performed subgroup analyses of patients by sex, coronary stent type (i.e. drug eluting stents and bare metal stents), clinical presentation during admission for PCI, and elective versus urgent hospitalization for surgery. Sensitivity analyses were performed for patients undergoing major vascular and orthopedic surgery.

In all analyses, sampling weights were applied to determine national incidence estimates, including pre-specified clustering and strata, unless otherwise noted.²² Statistical analyses were performed using SPSS 25 (IBM SPSS Statistics, Armonk, NY). Statistical tests are two-sided and P-values <0.05 were considered to be statistically significant. The NRD is a publicly available, de-identified dataset, and the study was exempt from institutional board review. This research is supported in part by an NYU CTSA grant, UL1 TR001445 and KL2 TR001446, from the National Center for Advancing Translational Sciences, National Institutes of Health. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

Results:

Patients Undergoing PCI

A total of 227,349 patients underwent PCI in the first 6 months of 2014. A majority of PCI (66.2%, n=150,519) were performed for acute myocardial infarction. Overall, 5,970 patients (2.6%) died in-hospital after PCI. Among the patients who survived, the mean age was 64.5 years and 67.8% of patients were men. Demographics and baseline characteristics of the remaining 221,379 individuals who underwent PCI and survived to hospital discharge are shown in Table 1.

Table 1.

Characteristics of patients with and without hospitalization for non-cardiac surgery within 6 months of percutaneous coronary intervention.

	PCI without NCS at 6 months (n=213,683)	PCI with NCS at 6 months (n=7,696)	p-value
Demographics & Clinical Characteristics
Age, Years (Std. Error)	64.5 (0.10)	67.5 (0.23)	<0.001
Female Sex (%)	68434 (32.0%)	2847 (37.0%)	0.001
Obesity	37374 (17.5%)	1375 (17.9%)	0.612
Hypertension	165334 (77.4%)	6291 (81.7%)	0.001
Dyslipidemia	152763 (71.5%)	5220 (67.8%)	<0.001
Diabetes Mellitus	79899 (37.4%)	3776 (49.1%)	<0.001
Chronic Kidney Disease	33451 (15.7%)	2335 (30.3%)	0.001
End Stage Renal Disease	5695 (2.7%)	846 (11.0%)	0.001
Prior CABG	15432 (7.2%)	749 (9.7%)	0.001
Prior PCI*	45640 (21.4%)	1784 (23.2%)	0.026
Peripheral Vascular Disease	23532 (11.0%)	2181 (28.3%)	0.001
Congestive Heart Failure	3301 (1.5%)	320 (4.2%)	0.001
Valvular Heart Disease	1106 (0.5%)	127 (1.7%)	0.001
Atrial Fibrillation	27368 (12.8%)	1430 (18.6%)	0.001
Anemia	24849 (11.6%)	1829 (23.8%)	0.001
Malignancy	4091 (1.9%)	391 (5.1%)	0.001
Chronic Pulmonary Disease	38417 (18%)	1781 (23.1%)	0.001
Hospital Presentation
Acute Myocardial Infarction	140803 (65.9%)	4462 (58%)	0.001
PCI with Bare metal stent	36143 (16.9%)	2161 (28.1%)	0.001
PCI with Drug Eluting Stent Placement	165300 (77.4%)	4815 (62.6%)	0.001

^*PCI was performed prior to the index hospitalization for PCI in 2014.

Readmission for Non-Cardiac Surgery

Among 221,379 adults who underwent PCI and survived to hospital discharge, 7,696 (3.5%) were readmitted for NCS within the first 6 months after PCI; of these, 21.8%, 39.6%, and 38.6% of patients were re-hospitalized for surgery within 1 month, 1–3 months and 3–6 months, respectively. A majority of the surgical hospitalizations (n=4516, 58.7%) were urgent, while 41.3% (n=3180) were electively planned. The frequency of elective admissions for non-cardiac surgery increased from 24.7% within 30 days of PCI to 45.6% after 1 to 6 months (p<0.001). Patients who were readmitted for surgery within 6 months were older, more likely to be women, and more likely to have cardiovascular comorbidities, including diabetes, kidney disease, and heart failure, and medical illnesses including anemia and malignancy. Patients who underwent surgery were less likely to have presented with AMI (58.0% versus 65.9%, p<0.001) and undergone PCI with a drug eluting stent (62.6% versus 77.4%, p<0.001). Full clinical characteristics associated with hospital readmission for NCS are shown in Table 1. In a multivariable model adjusted for demographics and clinical covariates, MI during index hospital admission (OR 0.75, 95% CI 0.69 – 0.82) and drug eluting stent placement (OR 0.53, 95% CI 0.48 – 0.58) were associated with a lower likelihood of readmission for surgery (Supplemental Table 1).

Among those readmitted for NCS, perioperative MI occurred in 365 (4.7%) cases, of which 78 were fatal (21.4%). A total of 339 (4.4%) patients died during readmission for NCS after PCI. Death or myocardial infarction occurred in 626 cases (8.1%). Documented bleeding occurred in 2,460 of patients undergoing surgery early after PCI (32.0%) and transfusion of packed red blood cells was required in 1609 cases (20.9%). Among patients with bleeding, perioperative mortality was significantly higher than those patients without bleeding (7.9% [195 patients] versus 2.7% [143 patients], p<0.001).

Perioperative risks varied based on the time interval between PCI and NCS, as shown in Figure 2. Patients with surgery within ≤1 month of PCI had the greatest risk of death or MI (11.4%). Risks of death or MI during hospitalization for NCS 1–3 months after PCI (aOR 0.64, 95% CI 0.46–0.88) and 3–6 months after PCI (aOR 0.72, 95% CI 0.53–0.99) were significantly lower than risks of NCS within 1 month of PCI, after adjusting for age, sex, and urgent/emergent indication for hospital readmission. Bleeding risks were also greatest when surgery was performed within 1 month of PCI (Supplemental Figure 1).

Figure 2.

In-hospital adverse cardiovascular events during hospital readmission for non-cardiac surgery by time interval between PCI and surgery.

Subgroups:

Demographics:

Women were more likely to be readmitted for surgery within 6 months after PCI than men (4.0% versus 3.2%, p<0.001). Among patients readmitted for NCS after PCI, there no difference in perioperative death or MI during surgical readmission by sex (9.0% for women versus 7.6% for men, p=0.15) (Supplemental Figure 2).

Elective Noncardiac Surgery after PCI

Among 3,180 patients who were electively admitted for surgery within 6 months after PCI, perioperative MI occurred in 94 (3.0%) cases, of which 32 were fatal (34.0%). A total of 96 (3.0%) patients died during elective readmission for NCS after PCI, and death or myocardial infarction occurred in 159 cases (5.0%). Bleeding occurred in 698 of patients undergoing elective NCS after PCI (22.0%) and transfusion of packed red blood cells was administered in 447 cases (14.0%). Among patients electively hospitalized for surgery, 2,748 (86.4%) were admitted ≥1 month after PCI, and 1287 (40.5%) were performed ≥3 months after PCI. Vascular (36.0%), orthopedic (17.5%) and general (15.9%) surgeries were the most commonly performed primary procedures during elective hospitalizations for NCS. Risks of death or MI declined over time, from 6.9% when surgery was performed within 1 month to 4.3% when surgery was performed between 3- and 6-months post PCI (Figure 3). In contrast, patients who were urgently or emergently admitted for NCS within 6 months after PCI had a greater frequency of death or MI than patients those electively hospitalized, overall (10.3% versus 5.0%, p<0.001) and at all time intervals between PCI and surgery.

Figure 3.

In-hospital adverse cardiovascular events among patients who were electively readmitted for non-cardiac surgery, by time interval between PCI and surgery.

PCI Presentation & Stent Type

Patients who underwent PCI for acute MI were less likely to be readmitted for NCS within 6 months than patients who underwent PCI for stable coronary artery disease (3.1% vs. 4.2%, p<0.001), with no difference in the composite of perioperative death or MI between the two groups (8.2% vs. 8.0%, p=0.84); (Table 3). Patients who underwent PCI with DES were less likely to be readmitted for NCS within 6 months than patients who underwent PCI with BMS (3.0% vs. 4.1%, p<0.001), with no difference in perioperative death or MI among those undergoing NCS (7.4% vs. 7.3%, p=0.89). The frequency of perioperative adverse cardiovascular events stratified by the time interval between PCI and readmission for NCS are shown for patients grouped by the clinical indication for PCI (Supplemental Figure 3) and by coronary stent type (Supplemental Figure 4).

Table 3:

Perioperative outcomes by clinical indication for PCI and by stent type.

PCI Clinical Indication	Myocardial Infarction (MI) (n=145,266)	No MI (n=76,113)	P-value
Readmission for NCS	4,452 (3.1%)	3,233 (4.2%)	0.001
Perioperative MI	211/4,452 (4.7%)	154/3,233 (4.8%)	0.98
Perioperative Mortality	206/4,452 (4.6%)	133/3,233 (4.1%)	0.50
Perioperative MACE	367/4,452 (8.2%)	259/3,233 (8.0%)	0.84
Stent Type	Drug Eluting Stent (n=170,115)	Bare Metal Stent (n=36,113)	Angioplasty Only (n=15,151)	P-value
Readmission for NCS	4815 (2.8%)	2058 (5.7%)	824 (5.4%)	0.001
Perioperative MI	202/4815 (4.2%)	79/2058 (3.8%)	84/824 (10.3%)	<0.001
Perioperative Mortality	213/4815 (4.4%)	82/2058 (4.0%)	44/824 (5.3%)	0.60
Perioperative MACE	370/4815 (7.7%)	135/2058 (6.6%)	121/824 (14.7%)	0.001

Non-Cardiac Surgery Subtype

Among the 7,696 patients who were readmitted for NCS within 6 months of PCI, 72.1% had procedure codes for 1 surgical subtype and 27.9% had codes ≥2 surgical subtypes during hospitalization. The primary surgical procedure during the hospitalization was vascular surgery in 25.6%, orthopedic surgery in 22.1%, and general surgery in 19.5% patients (Table 2). A majority of hospitalizations for primary vascular surgery within 6 months of PCI were elective; only 42% of procedures occurred during urgent admissions. In contrast, a majority of readmissions for the remaining surgical subtypes, including general and orthopedic surgery, were urgent or emergent (Table 2). The frequencies of perioperative adverse cardiovascular events complicating orthopedic, general, and vascular surgeries stratified by the time interval between PCI and NCS are shown in Supplemental Figure 5. All surgical procedures performed during hospital readmission are reported in Supplemental Table 2.

Table 2.

Primary surgery types during hospital readmission, overall and within subgroups of urgent and elective hospitalization for noncardiac surgery (NCS).

Surgery Type	All Readmissions for NCS	Urgent Readmission for NCS	Elective Readmission for NCS	% Urgent Surgical Readmissioin
Vascular Surgery	1974 (25.6%)	830 (18.4%)	1144 (36%)	42.0%
Orthopedic Surgery	1704 (22.1%)	1147 (25.4%)	557 (17.5%)	67.3%
General Surgery	1498 (19.5%)	992 (22.0%)	506 (15.9%)	66.2%
Skin/Breast Surgery	968 (12.6%)	651 (14.4%)	317 (10.0%)	67.3%
Thoracic Surgery	667 (8.7%)	352 (7.8%)	315 (9.9%)	52.8%
Genitourinary Surgery	494 (6.4%)	320 (7.1%)	174 (5.5%)	64.8%
Neurosurgery	243 (3.2%)	141 (3.1%)	102 (3.2%)	57.6%
Other Surgery	148 (1.9%)	83 (1.8%)	65 (2.0%)	56.1%

Discussion:

In this analysis of a large contemporary cohort of patients in the United States undergoing PCI, 3.5% were readmitted for NCS within 6 months of PCI, corresponding to up to ~30,000 patients each year nationwide. Early surgery was complicated by MI in 4.7% of cases, 21% of perioperative MI were fatal, and bleeding was documented in nearly one third of cases. All-cause mortality occurred in 4.4% of patients readmitted for NCS. Among the 75% of patients who underwent DES placement during the index PCI, 2.8% were readmitted for NCS within 6 months, despite clinical practice guideline recommendations to delay surgery for at least 6 to 12 months after DES PCI.^13–15 Among patients who required NCS within 6 months of PCI, 41% of patients were electively admitted for NCS. Outcomes during elective hospitalization for surgery after PCI were more favorable than those for urgent or emergent readmission. Still, 3% of patients died during an elective hospitalization for surgery after PCI.

The present study is the first to provide a contemporary perspective on the incidence of NCS early after PCI in a representative sample of hospitals in the United States among women and men and in the era of second-generation drug eluting stents and after changes to guidelines discouraging NCS after PCI. In prior studies, 5.1% to 7.5% of patients required NCS within 6 months of PCI.^{2, 6} An analysis of 126,773 patients undergoing PCI at the VA from 2000 to 2010 reported the frequency of surgery declined over time, with 6.6% requiring surgery within 1 year of DES PCI in the final year of the analysis.³ The lower frequency of NCS after PCI in the present analysis likely reflects a continuation of this trend. The present study expands upon the prior observational studies from the United States that were restricted to US veterans, included 98% men, reflected practice patterns with first generation DES, and included data collected largely before major changes in perioperative guidelines were published recommending delays in surgery post-PCI.^{3, 11, 13}

The prevalence of coronary artery disease in patients undergoing NCS has increased over time, and it is estimated that 120,000 adults have an MI after NCS in the US every year.^23–25 Recent PCI confers a substantial risk of perioperative MI, and MI after NCS is associated with adverse events and significant morbidity and mortality.^{1, 6, 19} In the present analysis, the incidence of perioperative MI early after PCI was significantly greater than the ~0.7% incidence of perioperative MI previously reported in all US patients undergoing NCS in 2014, and MI were associated with a high case fatality rate.^{17, 24} These data are consistent with older studies reporting frequent adverse cardiovascular events (ranging from 3 to 11%) when NCS is performed within 6–12 months after PCI.^{1, 3, 5, 8, 10, 11} However, the risks depend on the characteristics of the surgical population, the interval between PCI and surgery, and definitions of cardiovascular events.

To avoid cardiovascular complications, patients who are planned for PCI should be queried about any anticipated need for NCS, as this information may guide the strategy for coronary revascularization. Guideline directed medical therapy may be preferred to PCI in patients with stable ischemic heart disease and planned NCS, since a large randomized controlled trial did not demonstrate a reduction in death or MI with revascularization compared with medical therapy.²⁶ Unfortunately, a majority of hospitalizations for NCS in the present analysis were classified as urgent or emergent, and it is often difficult to predict which patients planned for PCI will need NCS. Among the 41% of patients who were electively hospitalized for NCS within 6 months of PCI, substantial risks of death or MI in the perioperative period were observed. Longer delays to surgery were associated lower risks of adverse cardiovascular events. In patients in whom PCI is deemed essential, the need for NCS may affect the choice of stent and duration of DAPT. Historically, bare metal stents have been selected in patients at risk for early NCS or bleeding post-PCI. However, contemporary 2^nd generation DES currently require a minimum of only 3–6 months of DAPT in stable patients, and even shorter DAPT durations of 1–3 months may be acceptable for biodegradable polymer and polymer-free DES.²⁷ Stents with the lowest risk of thrombosis and the shortest requirements for DAPT should be preferred in patients who require NCS early after PCI. Although guidelines initially recommended delaying NCS for 1 month after BMS implantation and 12 months after DES,¹⁴ recent evidence suggests that surgery at 6 months after DES PCI, or even earlier, may be safe.^{1, 2, 11, 28} Based on the current study findings, a delay of at least 3–6 months to elective NCS is advisable.

Study Limitations

Data are derived from diagnosis and procedure codes and are subject to reporting bias and/or errors in coding. First, the diagnosis of perioperative AMI during readmission for surgery may be under-reported or missed entirely, since up to two-thirds of perioperative MI are clinically silent and may not be recognized without routine biomarker screening.^29–31 Myocardial injury after non-cardiac surgery (MINS) occurs in 17 – 24% of cases in large observational registries, depending on the sensitivity of the cardiac troponin assay, and is associated with increased post-operative 30-day and long-term mortality.^29–32 MINS has been formally recognized as an important entity in the 4^th Universal Definition of MI.²⁹ Unfortunately, approaches to post-operative surveillance with troponin measurement and the frequency of MINS without coded MI were not available in the NRD. Second, discrete clinical data, including the results of diagnostic coronary angiography, were not captured in this administrative dataset. Thus, we were unable to account for the extent and severity of coronary artery disease or the completeness of revascularization with PCI. In an analysis of 12,486 non-cardiac surgeries performed at the VA in patients with prior PCI, incomplete revascularization was associated with a 19% increase in 30-day post-operative MACE and a 37% increased risk of perioperative MI.³³ Documentation of stent type was based on ICD-9 procedure codes, and errors in coding may have led to lower than expected frequency of drug eluting stent use in this analysis. Still, these data are consistent with prior reports that suggest that bare metal stents are still routinely used in roughly 25% of PCI in clinical practice.³⁴ Third, perioperative medications, specifically use of antiplatelet and anti-thrombotic regimens, were not available. Interruption of DAPT within 30 days of PCI is strongly associated with stent thrombosis, even in second-generation cobalt chromium everolimus-eluting DES.³⁵ Perioperative discontinuation of antiplatelet therapy has been associated with perioperative MACE.³⁶ In patients with prior stents, perioperative aspirin continuation is associated with a lower incidence of death or MI (HR 0.5, 95% CI 0.26–0.95) with no association between aspirin and bleeding.³⁷ Current perioperative guidelines recommend continuation of aspirin throughout the perioperative period and continuation of DAPT only when surgical bleeding risks are low. When a P2Y12 inhibitor is interrupted for surgery, it should be resumed post-operatively as soon as is possible.^{14, 15, 38} Fourth, the sequence of NCS preceding AMI could not be determined in this database, but NCS is contraindicated early after AMI. Fifth, only in-hospital outcomes were available from the NRD, which may lead to underestimation of perioperative event rates.

Conclusions:

In the present analysis, 3.5% of patients were readmitted for NCS within 6 months post-PCI, corresponding to up to ~30,000 patients each year nationwide. Early surgery was complicated by MI in 4.7% of cases, 21% of perioperative MI were fatal, and bleeding rates were high. All-cause mortality occurred in 4.4% of patients readmitted for surgery. The greatest risks for death or MI were observed when NCS was performed within the first month after PCI. Substantial risks were also observed in patients who were electively admitted for NCS at all time points in the first 6 months after PCI. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.

Figure 1.

Time to Readmission for Non-Cardiac Surgery after PCI

Abbreviations List:

AMI

Acute Myocardial Infarction

BMS

Bare Metal Stent

CCS

Clinical Classifications Software

CABG

Coronary Artery Bypass Grafting

DES

Drug Eluting Stent

HCUP

Healthcare Cost and Utilization Project’s

NRD

Nationwide Readmission Database

NCS

Non-Cardiac Surgery

PCI

Percutaneous Coronary Intervention