title: Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery.
abstract: Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown.
  
  
  
  We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics.
  
  
  
  Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients.
  
  
  
  One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.
authors.affiliation: VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO, USA. Javier.valle@ucdenver.edu.|Division of Cardiology, University of Colorado Hospital, 12631 E. 17th Street, B130, Aurora, CO, 80045, USA. Javier.valle@ucdenver.edu.
authors.forename: Javier A
authors.initials: JA
authors.lastname: Valle
authors.affiliation: Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Graham
authors.affiliation: Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
authors.forename: Aerin
authors.initials: A
authors.lastname: DeRussy
authors.affiliation: Veterans Affairs Boston Health Care System, Boston University and Harvard Medical School, Boston, MA, USA.
authors.forename: Kamal
authors.initials: K
authors.lastname: Itani
authors.affiliation: Stanford University School of Medicine, Palo Alto, CA, USA.
authors.forename: Mary T
authors.initials: MT
authors.lastname: Hawn
authors.affiliation: VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO, USA.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
mesh_terms: D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006470:Hemorrhage / Q000453:epidemiology; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D020521:Stroke / Q000453:epidemiology; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology
chemical_list: D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors