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

Abstract

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.

Early-Staged Carotid Artery Stenting Prior to Coronary Artery Bypass Grafting: Analysis of the Early and Mid-Term Results in Comparison with a Consecutive Cohort of Isolated Coronary Artery Surgery Patients

“…Furthermore, in the last 5 years, the need to urgently perform CABG on patients undergoing single or double anti-aggregating therapy has become increasingly frequent, due to the highrisk coronary anatomy and because in clinical practice many patients have intracoronary stents positioned shortly before carrying out CABG, thus necessarily requiring the dual antiplatelet therapy. Anyway, we observed in a previously published study [28] that bleeding requiring surgical exploration in patients on dual antiplatelet therapy (aspirin plus clopidogrel), i.e., 44% of the sample, although higher (2.4% vs. 1.2%), did not increase the risk of in-hospital mortality.…”

Dual antiplatelet management in the perioperative period: updated and expanded systematic review

“…Of these, 8 compared suspending DAPT (defined as holding P2Y12 inhibition with continuation of acetylsalicylic acid [ASA]) at various preoperative timepoints, which we dichotomized as ≤ 2 days withdrawal or > 2 days withdrawal. Of note, 1 study that grouped 48–72 h was placed in the > 2 days withdrawal group [ 23 ]. A second study had comparison groups of 0–3 days and > 4 days, which were reassigned to ≤ 2 and > 2 withdrawal days, respectively [ 24 ].…”

“…There were 4 observational CABG studies that reported mortality risk differences across comparison arms (shown in Fig. 5 ) and 1 additional study [ 23 ] that reported mortality as odds ratios. None of these reported significant differences in patient death across DAPT management strategies.…”

“…There were too few CABG studies that reported similar cardiac outcomes to the graph. Nardi and colleagues [ 23 ] observed no incidences of myocardial infarction for all DAPT management strategies, which included holding P2Y12 inhibition for 0 to 4 days prior to CABG. In a multicenter observational study of patients undergoing isolated CABG, Gielen et al found no significant association between the last use of DAPT and MACE (odds ratio [OR] = 0.85, 95% CI [0.64, 1.14], P = 0.27).…”