Antiplatelet therapy at the time of coronary artery bypass grafting: a multicentre cohort study

Kremke, Michael; Tang, Mariann; Bak, Mikkel; Kristensen, Katrine Lawaetz; Hindsholm, Karsten Brøgger; Andreasen, Jan Jesper; Hjortdal, Vibeke E.; Jakobsen, Carl-Johan

doi:10.1093/ejcts/ezt230

Cited by 36 publications

(23 citation statements)

References 23 publications

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“…3,4 This effect has been attributed in part to the increased bleeding risk and perioperative stent thrombosis that results from an imperfect balance of perioperative anticoagulation. 5 Improved understanding of perioperative anticoagulation and optimal timing of surgery after PCI-S may decrease the rate of perioperative complications, with some reports suggesting no early adverse effects. 6,7 …”

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confidence: 99%

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

Nauffal

Schwann

Yammine

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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Objective Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease. Methods We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996–2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort. Results In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037). Conclusions Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S.

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confidence: 99%

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

Nauffal

Schwann

Yammine

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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“…In a multi centre cohort study Kremke et al concluded that preoperative anti platelet is associated with increased bleeding and greater transfusion requirements after CABG. Clopidogrel was found to be an independent risk factor for severe post operative bleeding 10. Similarly Goldman et al in a multi centred randomised trial showed that preoperative aspirin is associated with more bleeding, transfusion requirements.…”

Section: Discussionmentioning

confidence: 84%

Risks and benefits of giving early Aspirin within 6 hours of CABG: A retrospective analysis

Khan

Jalal

et al. 2017

Pak J Med Sci

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Background & Objective:Antiplatelet drugs are frequently used after coronary artery bypass graft (CABG) surgery to prevent venous graft occlusion. The fear of bleeding complications prevents them to be given early post operatively, which is the time when antiplatelets use confers maximum benefit. Our objective was to determine the effect and influence of early aspirin therapy on fatal and nonfatal bleeding complications and blood requirements after coronary bypass surgery (CABG).Methods:The patients who only underwent coronary artery bypass surgery for the first time in the past three years and did not have any bleeding diathesis were retrospectively analyzed from the cardiac surgery database of CPEIC Multan. The patients either received aspirin within six hours of CABG or had it given after 12 hours. The patients were analyzed for mean blood loss and number of blood units transfused. SPSS was used for statistical analysis. P value < 0.05 was considered significant.Results:Total 281 patients received aspirin within six hours while 326 patients did not. Mean blood loss in early aspirin group was 727ml as compared to 767ml in the other group (p value 0.74). The median number of blood units transfused was 2 (p value 0.98). Our results did not show any statistical difference in both the groups.Conclusion:Aspirin can safely be given early after CABG without the fear of bleeding complications thus conferring the advantage of increased graft patency.

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“…Given the association between P2Y 12 inhibitor use and surgical bleeding, the American College of Cardiology Foundation and American Heart Association advise discontinuation of clopidogrel for ≥5 days prior to elective CABG (class I recommendation, level of evidence [LOE] B). These guidelines reflect data from studies that associate perioperative clopidogrel exposure with increased bleeding, blood‐product transfusion, reoperation, and longer hospitalization, particularly if administered within 5 days prior to CABG …”

Section: Introductionmentioning

confidence: 93%

Point‐of‐Care Platelet Function Testing Predicts Bleeding in Patients Exposed to Clopidogrel Undergoing Coronary Artery Bypass Grafting: Verify Pre‐Op TIMI 45—A Pilot Study

Reed

Kumar

Guo

et al. 2015

Clinical Cardiology

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Background: Guidelines recommend delaying coronary artery bypass grafting (CABG) for 5 days after discontinuing clopidogrel. However, platelet function may recover quicker in certain individuals. Hypothesis: We hypothesized that perioperative measurement of platelet function with a point-of-care P2Y 12 inhibitor assay could predict bleeding during CABG in patients exposed to clopidogrel. Methods: Verify Pre-Op TIMI 45 was a prospective pilot study of 39 patients on clopidogrel who subsequently underwent CABG. Preoperative on-treatment platelet reactivity was assessed with VerifyNow P2Y 12 Reaction Units (PRU), with higher PRU indicating more reactive platelets. Outcomes were stratified by PRU quartiles, as well as prespecified cutpoints for the lowest quartile (PRU 173), a cutpoint for major bleeding determined by the Youden index using receiver operator curve analysis (PRU 207), and clopidogrel resistance (PRU 230). Results: Patients in higher PRU quartiles experienced smaller decreases in hemoglobin and hematocrit (P < 0.05 for all comparisons), less major bleeding (P = 0.021), and less major or minor bleeding (P = 0.003). Patients above the PRU 207 and 230 cutpoints had less chest-tube output (P = 0.041 and P = 0.012, respectively), less major bleeding (P = 0.005 and P = 0.036, respectively), and less major or minor bleeding (P = 0.013 and P < 0.001, respectively). By receiver operator curve analysis, preoperative PRU ≤ 207 discriminated between patients with and without major bleeding during surgery (area under the curve: 0.76, 95% confidence interval: 0.59-0.94, P = 0.018). Conclusions: In this pilot study, we found that point-of-care platelet function assessment could predict bleeding in patients recently exposed to clopidogrel undergoing CABG.

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Antiplatelet therapy at the time of coronary artery bypass grafting: a multicentre cohort study

Abstract: Preoperative APT is associated with increased bleeding and greater transfusion requirements after CABG. Clopidogrel exposure is associated with greater reoperation rates and is an independent risk factor for severe postoperative bleeding.

Cited by 36 publications

References 23 publications

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

Risks and benefits of giving early Aspirin within 6 hours of CABG: A retrospective analysis

Point‐of‐Care Platelet Function Testing Predicts Bleeding in Patients Exposed to Clopidogrel Undergoing Coronary Artery Bypass Grafting: Verify Pre‐Op TIMI 45—A Pilot Study

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