When can elective non‑cardiac surgery be performed after a recent acute coronary syndrome (ST‑segment‑elevation myocardial infarction or non‑ST‑segment‑elevation myocardial infarction) and how should antiplatelet therapy be managed?

Timing of Noncardiac Surgery After Acute Coronary Syndrome

For patients with ACS who require elective noncardiac surgery, delay the procedure for at least 12 months if a drug-eluting stent was placed, or 6 months if no stent was placed or if a bare-metal stent was used. 1

Risk Stratification Based on ACS Management

The timing of surgery depends critically on whether the ACS was managed with percutaneous coronary intervention (PCI) and what type of stent was placed:

ACS Managed with Drug-Eluting Stent (DES)

• Elective surgery should be delayed ≥12 months after DES placement for ACS to minimize perioperative major adverse cardiac events (MACE) 1
• This represents a higher-risk scenario than stable CAD, with nearly 3-fold higher perioperative MACE risk 1
• Time-sensitive surgery may be considered at ≥3 months if the risk of delaying surgery outweighs the risk of stent thrombosis, though this carries substantial risk 1
• Surgery within 30 days of DES placement is potentially harmful and should be avoided due to high stent thrombosis risk 1

ACS Managed with Bare-Metal Stent (BMS)

• Delay elective surgery for at least 30 days after BMS placement 1
• The risk of stent thrombosis is highest in the first 4-6 weeks post-PCI 1

ACS Managed with Balloon Angioplasty Only (No Stent)

• Delay elective surgery for a minimum of 14 days after balloon angioplasty 1

ACS Managed Medically (No PCI)

• Optimal timing appears to be 180 days (6 months) after the ACS event 2
• This allows for cardiac stabilization and optimization of medical therapy

Antiplatelet Management During the Perioperative Period

If Surgery Cannot Be Delayed Beyond Recommended Timeframes

Continue aspirin (75-100 mg daily) throughout the perioperative period whenever possible to reduce cardiac events 1

For patients requiring surgery within critical timeframes:

• Within 30 days of BMS or <3 months of DES: Continue dual antiplatelet therapy (DAPT) unless bleeding risk clearly outweighs stent thrombosis risk 1
• Between 3-12 months after DES for ACS: Strongly consider continuing DAPT through the perioperative period 3

P2Y12 Inhibitor Management When Discontinuation Is Necessary

If DAPT must be interrupted for high bleeding-risk surgery:

• Clopidogrel: Discontinue 5 days before surgery 1, 4
• Ticagrelor: Discontinue 5 days before surgery 1, 4
• Prasugrel: Discontinue 7 days before surgery 1, 4
• Restart P2Y12 inhibitor within 24 hours after surgery when hemostasis is secure 4

Bridging Antiplatelet Therapy

In select high-thrombotic-risk patients, perioperative bridging with intravenous antiplatelet therapy (eptifibatide or tirofiban) may be considered if surgery cannot be deferred and occurs <6 months after DES or <30 days after BMS 1

Critical Pitfalls to Avoid

Never perform elective surgery within 30 days of any coronary stent placement if antiplatelet therapy must be interrupted—this is associated with catastrophic stent thrombosis rates 1

Do not routinely discontinue aspirin perioperatively in patients with prior ACS or PCI, as the cardiac risk typically outweighs bleeding risk in most surgical procedures 1

Avoid assuming that BMS and DES carry equivalent risk—while some data suggest similar MACE rates at 6 months, the indication for PCI (ACS vs. stable CAD) is the more important risk factor 1

Multidisciplinary Decision-Making Algorithm

When faced with a patient requiring surgery after ACS:

1. Determine the time elapsed since ACS event and type of intervention performed (medical management, balloon angioplasty, BMS, or DES) 3, 5

2. Classify surgery urgency: truly emergent, urgent/time-sensitive, or elective 1

3. Apply timing recommendations:

   • DES for ACS: Delay ≥12 months for elective surgery 1
   • DES for stable CAD: Delay ≥6 months 1
   • BMS: Delay ≥30 days 1
   • Balloon angioplasty: Delay ≥14 days 1
   • Medical management only: Delay ≥6 months 2

4. For time-sensitive surgery that cannot wait: Assess whether DAPT can be safely continued based on surgical bleeding risk 1

5. If DAPT must be interrupted: Consider bridging therapy for highest-risk patients and ensure aspirin continuation whenever possible 1

6. Optimize medical therapy: Ensure patient is on high-intensity statin, beta-blocker (if already taking), and ACE inhibitor/ARB (especially if diabetic) 2

The evidence consistently demonstrates that perioperative MACE risk remains elevated for up to 1 year after ACS, with the highest risk in the first 6 months 1. The 12-month delay recommendation for ACS with DES represents the most conservative and safest approach based on current evidence 1.