Evidence for Preoperative Aspirin Improving Major Outcomes in Patients With Chronic Kidney Disease Undergoing Cardiac Surgery

Abstract

Aim of review:Diabetes is a chronic and slowly progressing disease that has a tendency to develop rapidly deteriorating complications such as major adverse cardiovascular events (MACE), especially under the stress of surgery. While clinical strategy to prevent MACE is controversial and uncertain. Method: We conducted a comprehensive review of current clinical strategies in preventing perioperative MACE, in particularly related to diabetic patients. Results: The major findings are: 1) Current clinical studies have demonstrated that coronary artery bypass graft (CABG) is still a better therapy than percutaneous coronary intervention (PCI) on the ground of reducing repeat revascularization, myocardial infarction and death for most diabetic patients with left main-stem and multivessel coronary artery disease who require revascularization, however, it remains to be studied whether coronary revascularization before noncardiac surgery can protect diabetic patients from MACE; 2) There is lack of evidence that intensive or "tight" glycemic control perioperatively can reduce MACE, instead, a moderate or less stringent glucose management probably is safer for patients undergoing surgery;3) The recent results of clinical trials on beta-blockers appear to be disappointing in preventing MACE in surgical patients, including diabetic patients. Meanwhile, the perioperative therapy with statins, angiotensin-converting enzyme inhibitors or multifactorial interventions is promising in preventing MACE in diabetic patients. Summary: Further studies targeted at preventing MACE in diabetic patients undergoing surgery are needed in order to fight this major health problem in perioperative medicine. ABSTRACT

The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis

“…A total of 3922 patients from 12 RCTs and 30 893 patients coming from 28 observational studies met our inclusion criteria and were included in the meta‐analysis. Characteristics of the studies are presented in Tables and .…”

“…Sixteen observational studies reported 30‐day mortality with an aggregate of 27 944 patients. Pooling the results of the observational studies, preoperative aspirin showed a significant decrease in postoperative mortality by 32% (OR 0.68; 95%CI 0.55‐0.85; P = 0.0004; I 2 = 23%; P heterogeneity = 0.19) (Figure ).…”

“…Pooling the results of both RCTs and observational studies, preoperative aspirin showed a significant decrease in postoperative mortality by 29% (OR 0.71; 95%CI 0.6‐0.84; P = 0.0001; I 2 = 7%; P heterogeneity = 0.36). A total of 31 306 patients have been pooled to assess 30‐day mortality of which 93.03% underwent CABG with or without heart valve surgery (Figure ).…”

“…On the other hand, the Society of Thoracic Surgeons Guidelines on “Use of antiplatelet drugs in patients having cardiac and noncardiac operations” suggest that discontinuation of preoperative aspirin therapy before purely elective operations and in high‐risk patients is reasonable to decrease the risk of bleeding . Several observational studies showed that preoperative aspirin might improve outcomes not only in patients undergoing CABG but also in patients undergoing any other cardiac surgical procedures . Therefore, we performed a systematic review and meta‐analysis to assess the influence of preoperative aspirin administration on patients undergoing all types of cardiac surgery.…”

Acute kidney injury in cardiac surgery

“…A recent retrospective cohort study suggests that preoperative acetylsalicylic acid may have a protective effect against AKI in patients with preoperative CKD [69]. The severity of CKD is calculated by the Modification of Diet in Renal Disease algorithm, which classifies it as Stages 1-5 based upon an eGFR of greater than 90, 60-89, 30-59, 15-29, and less than 15 ml/min/1.73 m 2 , respectively.…”