Stopping antiplatelet medication before coronary artery bypass graft surgery: is there an optimal timing to minimize bleeding?

Gielen, Chantal L.I.; Bruggemans, Eline F.; Stijnen, Theo; Eikenboom, Jeroen; Tavilla, Giuseppe; Brand, Anneke; Klautz, Robert J.M.

doi:10.1093/ejcts/ezv269

Cited by 9 publications

(6 citation statements)

References 24 publications

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“…10 In addition, Gielen et al thought there was no obviously relevant effect on bleeding volume, which could indicate an optimal discontinuation day for aspirin alone or with clopidogrel. 11 A nationwide study found that discontinuation of ticagrelor 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications, but the risk was increased with clopidogrel discontinuation 3 days prior to surgery, which was similar to our result. 12 For the 5-day preoperative discontinuation of clopidogrel, the ESC guidelines 13 provide class IIa, level B recommendations for patients who need to undergo nonemergency cardiac surgery.…”

Section: Discussionsupporting

confidence: 89%

Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

Cheng¹,

Liu²,

Zhao³

et al. 2020

Angiology

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This retrospective study assessed the risk factors for adverse events following off-pump coronary artery bypass graft (CABG) surgery with dual antiplatelet therapy (DAPT). Records (between 2013 and 2017) were reviewed for patients who discontinued DAPT (clopidogrel 75 mg and aspirin 100 mg) ≤5 days before off-pump CABG. The primary outcome was the incidence of a Bleeding Academic Research Consortium (BARC) type 4 major event. Factors associated with bleeding events and perioperative myocardial ischemia were evaluated using multivariable logistic regression. The incidence of major bleeding events was 17.6% in 2012 patients. Adjusted multiple logistic regression analysis showed that the risk of postoperative bleeding increased when DAPT was discontinued <3 days before surgery (day 2: adjusted odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.09-2.64; day 1: adjusted OR: 2.37, 95% CI: 1.49-3.77; day 0: adjusted OR: 2.45, 95% CI: 1.53-3.92). The adjusted risk of mortality (OR: 13.14, 95% CI: 4.55-37.94) was increased with bleeding complications. In subgroup analysis, perioperative myocardial ischemia was related to increased blood loss (adjusted OR: 1.10, 95% CI: 1.02-1.18). Aspirin and clopidogrel should optimally be discontinued >3 days before CABG to reduce the risk of bleeding complications, myocardial ischemia, and death.

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Section: Discussionsupporting

confidence: 89%

Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

Cheng¹,

Liu²,

Zhao³

et al. 2020

Angiology

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“…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.…”

Section: Resultsmentioning

confidence: 99%

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

Shah¹,

Urtecho²,

Firwana³

et al. 2022

Mayo Clinic Proceedings: Innovations, Quality & Outcomes

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“…Acute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) (1). Excessive bleeding after cardiac surgery is associated with transfusion of blood products, which is associated with increased morbidity, mortality and high costs (2).…”

Section: Introductionmentioning

confidence: 99%

Coronary Artery Bypass Graft Surgery in Patients on Ticagrelor Therapy Is Not Associated with Adverse Perioperative Outcomes

Diab

Arazi

Sternik

et al. 2021

Preprint

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Background Management of patients treated with ticagrelor is challenging, as stopping Ticagrelor prior to coronary bypass graft surgery (CABG) may increase the risk of acute stent thrombosis. The aim of the study was to compare bleeding complications in patients treated with ticagrelor combined with acetylsalicylic acid (ASA) until one day before surgery versus ASA alone. Methods Bleeding complications, defined as the composite of red blood cells transfusion ≥ 1000ml, chest drainage ≥ 2000ml, and bleeding requiring surgical re-exploration, were compared in 161 patients, 101 on preoperative acetylsalicylic acid (ASA) alone (group A) and 65 on ticagrelor + ASA (group B). Results There were no differences in bleeding complications between the two groups (26% vs. 27% in group A and B, respectively), with similar chest drainage in the first 24 hours (569 ± 393ml and 649 ± 427ml, respectively). Conclusions Continuing ticagrelor until coronary artery bypass surgery was not associated with increased bleeding complications, suggesting that with appropriate perioperative management, continuing ticagrelor until surgery may be safe.

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Stopping antiplatelet medication before coronary artery bypass graft surgery: is there an optimal timing to minimize bleeding?

Abstract: There is no clinically relevant effect on blood loss indicating an optimal stop day for ASA alone or in combination with Clo. Last use on Day -2 resulted in the reduction of percentage of patients receiving platelet transfusions, especially in the ASA+Clo group.

Cited by 9 publications

References 24 publications

Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery

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

Coronary Artery Bypass Graft Surgery in Patients on Ticagrelor Therapy Is Not Associated with Adverse Perioperative Outcomes

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