Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis

Vuilliomenet, Thierry; Gebhard, Caroline E.; Bizzozero, Chiara; Glauser, S. J.; Blum, Steffen; Buser, Andreas; Bolliger, Daniel; Grapow, Martin; Siegemund, Martin

doi:10.1093/icvts/ivy330

Cited by 13 publications

(6 citation statements)

References 20 publications

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“…Hansson et al in ). The authors found that discontinuation of ticagrelor or prasugrel for less than 24 hours was associated with significant higher postoperative bleeding and use of blood products (p < 0.001) [23].…”

Section: Discussionmentioning

confidence: 97%

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

Nardi

Pisano

Turturici

et al. 2021

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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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Section: Discussionmentioning

confidence: 97%

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

Nardi

Pisano

Turturici

et al. 2021

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“…31 There is clear evidence that P2Y 12 receptor inhibitors increase bleeding after cardiac surgery, especially with the newer and more potent drugs such as prasugrel or ticagrelor. 10,11,15,16 Various recent meta-analyses including >22,000 patients undergoing cardiac surgery assessed the benefits and bleeding risks of preoperative intake of P2Y 12 receptor inhibitors. 14,32,33 These meta-analyses suggested a certain protection against ischemic events but clearly demonstrated a 2-fold increased risk of bleeding and higher mortality in patients with continued P2Y 12 receptor inhibitor intake.…”

Section: Aspirinmentioning

confidence: 99%

“…However, postponing cardiac surgery for at least 2 days in patients taking ticagrelor and 3 days in patients taking prasugrel or clopidogrel significantly reduced the risk for massive perioperative bleeding in 2 retrospective analyses. 16,37 In patients with high risk of stent thrombosis, bridging with the novel intravenous P2Y 12 receptor antagonist cangrelor might be an option. 38,39 Cangrelor has a very short half-life of 3-to-6 minutes, and normal platelet function returns within less than 1 hour, allowing early surgery after discontinuation.…”

Section: Aspirinmentioning

confidence: 99%

“…Evidence for the optimal perioperative antiplatelet management in cardiac surgery patients is scarce, especially with the more recent and potent P2Y 12 receptor inhibitors, including prasugrel and ticagrelor. 15,16 Platelet function monitoring might help in decision-making. This narrative review focuses on the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients with CAD undergoing cardiac surgery.…”

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confidence: 99%

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Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery

Bolliger

Lancé

Siegemund

2021

Journal of Cardiothoracic and Vascular Anesthesia

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Although most physicians are comfortable managing the limited anticoagulant effect of aspirin, the recent administration of potent P2Y 12 receptor inhibitors in patients undergoing cardiac surgery remains a dilemma. Guidelines recommend discontinuation of potent P2Y 12 inhibitors 5-to-7 days before surgery to reduce the risk of postoperative hemorrhage. Such a strategy might not be feasible before urgent surgery, due to ongoing myocardial ischemia or in patients at high risk for thromboembolic events. Recently, different point-of-care devices to assess functional platelet quality have become available for clinical use. The aim of this narrative review was to evaluate the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients treated with antiplatelets, including aspirin or P2Y 12 receptor inhibitors, undergoing cardiac surgery. No objective superiority of one point-of-care device over another was found in a large meta-analysis. Their accuracy and reliability are generally limited in the perioperative period. In particular, preoperative platelet function testing has been used to assess platelet contribution to bleeding after cardiac surgery. However, predictive values for postoperative hemorrhage and transfusion requirements are low, and there is a significant variability between and within these tests. Further, platelet function monitoring has been used to optimize the preoperative waiting period after cessation of dual antiplatelet therapy before urgent cardiac surgery. Furthermore, studies assessing their value in therapeutic decisions in bleeding patients after cardiac surgery are scarce. A general and liberal use of perioperative platelet function testing is not yet recommended.

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“…Деякі дослідники повідомляють, що припинення приймання ПАТТ більш ніж на 72 години перед невідкладною АКШ не було пов'язано з вищою частотою кровотеч порівняно з лікуванням монотерапією ацетилсаліциловою кислотою. Навпаки, припинення лікування менш ніж на 24 години було пов'язано з більш частим використанням препаратів крові [9]. Отже, питання щодо терміну 24-72 год залишається відкритим.…”

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The Risk of Perioperative Bleeding in Patients with Dual Antiplatelet Therapy

Domanskyy

Gabriyelyan

Beregovoy

et al. 2021

ujcvs

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Background. Patients with dual antiplatelet therapy have high risk of perioperative bleeding. In this article we evaluated the risk of bleeding in patients whose antiplatelet therapy had not been canceled before coronary artery bypass grafting (CABG). The aim. To investigate and evaluate the risk of intra- and postoperative bleeding in patients who underwent CABG during antiplatelet therapy. Materials and methods. In the study, 47 case reports of patients with coronary heart disease who underwent CABG were evaluated. The patients were divided into 2 groups. The first group included 26 patients who discontinued antiplatelet therapy less than 5 days before the operation. The second group included 21 patients who discontinued antiplatelet therapy more than 5 days before the operation. Stratification of the risk of bleeding was performed using HAS-BLED Score for Major Bleeding Risk online calculator. Results and discussion. The major bleeding risk was 5.1 ± 1.4% and 4.4 ± 1.6% in the first and in the second group, respectively. In spite of higher risk of bleeding in the first group, there was no significant difference in intra- and postoperative bleeding complications. Conclusions. Candidates for surgical intervention who receive dual antiplatelet therapy have high risk of intra- and postoperative bleeding complications. In urgent cases when timely discontinuation of dual antiplatelet therapy is impossible and there is urgent need in the intervention, the latter must be performed. For patients who were prepared for CABG and discontinued dual antiplatelet therapy less than 5 days before the operation, sufficient volume of blood for transfusion must be provided.

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Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis

Cited by 13 publications

References 20 publications

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

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

Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery

The Risk of Perioperative Bleeding in Patients with Dual Antiplatelet Therapy

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