This paper describes the management of three patients for elective surgery with drug-eluting stents in the coronary circulation. The risks posed at the time of surgery by such patients include acute coronary syndromes, as a result of stent thrombosis, after cessation of anti-platelet therapy and excessive bleeding from continued anti-platelet therapy. We describe a regime for the management of such patients that successfully avoided these risks in three patients with paclitaxel drug-eluting stents requiring elective non-cardiac surgery.

Aim To determine whether pharmacist‐initiated electronic discharge prescribing would decrease discharge times for selected cardiology patients and improve the accuracy of prescribing by limiting deviations from the intended therapeutic plan. Method A cardiology project team identified system issues impeding patient flow through the ward, including the discharge medication pathway. The stages of the medication pathway were mapped before and after the intervention of pharmacist‐initiated electronic discharge prescribing. The accuracy of prescribing in both phases of the study was measured against evidence‐based standards agreed by the cardiology unit. Results 39 patients were recruited in phase 1 (usual practice) and 35 patients in phase 2 (pharmacist‐initiated discharge prescriptions). The time from a decision to discharge a patient to the completed prescription reaching the patient was significantly reduced from a median of 190 minutes to 50 minutes in the intervention arm (p < 0.0001). However, this result did not translate into patients leaving the hospital earlier. In phase 1, 26% of prescriptions (n = 39) contained at least one error, including 19 clinically significant omissions. In phase 2, no omissions were made but the signing doctor made two changes to the pharmacist‐initiated prescriptions that were unrelated to the evidence‐based standards. Conclusion This pilot study has shown that an experienced pharmacy specialist using an electronic discharge prescribing system can significantly reduce the time elements of the discharge medication pathway. In addition, errors of omission that deviate from evidence‐based practice are reduced. This practice model can be extended to other specialist areas.

The introduction of drug-eluting stents (DES) to interventional cardiology heralded a limited time of increased anaesthetic and surgical complications in patients implanted with these devices. The horns of the dilemma, in the anaesthetic and surgical management of patients in the first 3 -6 months after the 1 st generation DES insertion, were between the risk of bleeding from continued clopidogrel treatment and the risk of instent thrombosis and myocardial infarction following discontinuation of dual antiplatelet therapy, clopidogrel and aspirin. Initial accounts of early catastrophic cardiac and haemorrhagic complications, at the time of elective or emergency surgery, following DES insertion, were followed by equally worrying reports of in-stent thrombosis many months after DES insertion. Initial recommendations for the conduct of safe operations were propagated in the literature before formal guidelines were produced. This article summarises the issues identified in the development of interventional cardiology particularly DES and the requirement for ongoing antiplatelet therapy. The article reviews the treatment protocols that are still applicable for the different devices that have been deployed in clinical practice.

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