Perioperative management of antiplatelet treatment in patients undergoing isolated coronary artery bypass grafting in Dutch cardiothoracic centres

Abstract

Background International guidelines do not provide uniform recommendations regarding the use of antiplatelet treatment in the perioperative period in patients undergoing coronary artery bypass grafting (CABG). Methods A questionnaire was sent to all 16 cardiothoracic centres in the Netherlands to determine which antiplatelet treatment is used in the perioperative setting. Furthermore, a single-centre prospective observational cohort study was performed which included all patients undergoing isolated CABG in July 2014. Results Eleven centres responded to the survey. Acetylsalicylic acid monotherapy was discontinued before surgery in 6 centres. In patients with an acute coronary syndrome receiving dual antiplatelet therapy (DAPT), most centres discontinued the P2Y12 inhibitor preoperatively. DAPT was restarted after surgery in 4 centres. However, 6 centres continued DAPT in patients who had undergone coronary stenting within one month of surgery. In patients with coronary stents, variation in the management of antiplatelet therapy increased in proportion to the interval between stenting and surgery. A total of 70 patients were included in the registry. Acetylsalicylic acid monotherapy was discontinued in 51% of patients and restarted in all patients. P2Y12 inhibitor treatment was discontinued before surgery in 70% of patients and re-initiated after CABG in 29%. Conclusions Major differences were observed in the preoperative and postoperative management of antiplatelet treatment between different Dutch cardiothoracic centres and within a single centre. Part of this variation is probably due to lack of evidence and differences between the current guidelines; however, many of the strategies were not in accordance with any of these guidelines. Electronic supplementary material

Antiplatelet therapy with CABG: chaos in the Netherlands

“…In this issue of the Netherlands Heart Journal, Janssen et al present the results of a survey amongst the cardiothoracic centres in the Netherlands on their strategies of perioperative antithrombotic therapy in CABG in the Netherlands [7]. The bottom line is that there is a large variation in the use of antithrombotic therapy around CABG, which was quite similar to the situation 27 years ago [8].…”

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis

“…We included 17 studies (5 RCTs 28 , 29 , 30 , 31 , 32 and 12 cohorts 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ) that reported on 12,621 patients. The risk of bias for RCTs and cohort studies was low-to-moderate and moderate-to-high, respectively.…”

Effect of thrombelastography on timing of coronary artery bypass grafting

“…MA ADP provides significant value by guiding the selection of surgical timing. Typically, for elective CABG, patients with MA ADP <35 mm should wait for more than 5 days before surgery; patients with MA ADP ranged 35 mm-50 mm should wait for 3–5 days prior to surgery; and patients with MA ADP >50 mm are allowed to receive the surgery on the same day as medication withdrawal ( 4 , 17 ). In the present study, no significant difference was observed when comparing the postoperative 24-h chest drains among the three TEG sub-groups.…”

“…However, for patients scheduled for off-pump coronary artery bypass grafting (CABG), DAPT poses strong risk for perioperative bleeding in patients with CABG ( 3 ). Moreover, consumption of coagulation factor during cardiopulmonary bypass, dilution of fibrinogen and platelets, combined with other risk factors such as heparin and decreased body temperature, all result in depression on coagulation function, thus increasing the risk of perioperative bleeding, blood transfusion, postoperative mortality and rate of complication ( 4 ).…”