Guideline on antiplatelet and anticoagulation management in cardiac surgery

Abstract

This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

“…According to the European Association for Cardiothoracic Surgery (EACTS) guidelines, prophylactic anticoagulation for VTE should be commenced from the first postoperative day 3. However, an increased risk of bleeding and cardiac tamponade resulting from pharmacological thromboprophylaxis remains a major concern for patients who have undergone cardiac surgery 4.…”

Preoperative Aspirin Use and Its Effect on Adverse Events in Patients Undergoing Cardiac Operations

“…Decisions about preoperative aspirin therapy in patients undergoing CABG are made widely on the basis of individual and institutional experiences [11][12][13]. Actually, the American Heart Association, American College of Cardiology [18], The Society of Thoracic Surgeons (STS) [19], and the European Association for Cardio-Thoracic Surgery [20] even make different recommendations about when preoperative aspirin therapy should be terminated, ranging between 2 and 10 days before elective cardiac operations.…”

Antiplatelet therapy with CABG: chaos in the Netherlands

“…The most specific guideline from Europe [4] dates from 2008, and the American one is from 2014 [10]. The 2014 guideline issued by the European Association for Cardio-Thoracic Surgery [11] is not clear on this issue and focusses more on percutaneous revascularisation than CABG.…”

“…Oral anticoagulants have shown to be effective as well [2], but not superior to antiplatelet agents [3]. Therefore, aspirin has become the standard of care in the prevention of graft occlusion [4]. Nowadays, a complicating factor is the use of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 blocker (clopidogrel, prasugrel or ticagrelor) in patients who have recovered from acute coronary syndromes (ACS) [5,6].…”