A Difference in Bleeding and Use of Blood and Blood Products in Patients who Were Preoperatively on Aspirin or Dual Antiplatelet Therapy Before Coronary Artery Bypass Grafting

Štraus, Slavenka; Haxhibeqiri-Karabdić, Ilirijana; Grabovica, Sanja; Granov, Nermir

doi:10.5455/medarh.2018.72.31-35

Cited by 7 publications

(4 citation statements)

References 10 publications

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“…Acute coronary syndrome (ACS) patients receiving dual antiplatelet therapy (DAPT) who need emergent or urgent coronary artery bypass grafting (CABG) are at high risk of major bleeding [1], which can impair the outcome after cardiac surgery. The literature indicates that undergoing cardiac surgery while taking antiplatelet agents is associated with increased bleeding [2,3] and other adverse events, higher care needs, including duration of surgery and hospital stay, and increased morbidity and mortality. Significant intra-and postoperative bleeding may require the use of blood transfusions such as red blood cells (RBCs), which are strongly associated with long-term morbidity and mortality [4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Javanbakht

Trevor

Hemami

et al. 2019

PharmacoEconomics Open

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Background Acute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb ® , a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery. Objective The aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK. Methods A de novo decision analytic model, based on current treatment pathways, was developed to estimate the short-and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters. Results In emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators-delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53-77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit. Conclusions The implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.

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Section: Introductionmentioning

confidence: 99%

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Javanbakht

Trevor

Hemami

et al. 2019

PharmacoEconomics Open

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“…Clopidogrel is an irreversible platelet inhibitor, and normal platelet activity is not recovered until 5 to 10 days after its discontinuation. Cessation of clopidogrel is therefore recommended at least 120 hours or 5 days before CABG in order to limit the risk of bleeding [13,14]. In contrast, ticagrelor is a reversible P2Y 12 receptor inhibitor with a faster offset of platelet inhibition, i.e.…”

Section: Discussionmentioning

confidence: 99%

The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery

Nardi

Pisano

Turturici

et al. 2021

kitp

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Introduction: Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. Aim: We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). Material and methods: Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3-4 days (group A, n = 159), 48-72 hours or 2-3 days (group B, n = 126), < 24 hours or 0-1 day (group C, n = 24) prior to CABG. Results: Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). Conclusions: Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2-3 and > 3-4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.

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“…Basis of treatment for MI is the use of DAPT with the aim of reducing coagulation and ischemic events [ 7 , 23 ], on the other hand, this strategy increases the risk of bleeding [ 10 , 11 ], thus there is disagreement between cardiologists and cardiovascular surgeons regarding DAPT before CABG. The aim of this prospective cohort study was to evaluate the effect of DAPT with aspirin and clopidogrel up to the day before CABG on postoperative outcomes in patients with MI.…”

Section: Discussionmentioning

confidence: 99%

“…Despite the benefits of DAPT in the management of CABG candidate patients, this strategy also has its risks, as it can increase the risk of bleeding up to 50%. If one antiplatelet drug (Aspirin or clopidogrel) is used, the risk is 20% [ 10 , 11 ]. The amount of blood lost after CABG is a very important factor in the survival rate of MI patients [ 12 – 15 ].…”

Section: Introductionmentioning

confidence: 99%

Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study

et al. 2021

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Background Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. Methods In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. Results The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9–20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). Conclusions A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.

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A Difference in Bleeding and Use of Blood and Blood Products in Patients who Were Preoperatively on Aspirin or Dual Antiplatelet Therapy Before Coronary Artery Bypass Grafting

Cited by 7 publications

References 10 publications

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis

The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery

Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study

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