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Gupta AK, Kovoor JG, Leslie A, Litwin P, Stretton B, Zaka A, Kovoor P, Bacchi S, Bennetts JS, Maddern GJ. To be or not to be on: aspirin and coronary artery bypass graft surgery. Front Cardiovasc Med 2024; 11:1451337. [PMID: 39253391 PMCID: PMC11381263 DOI: 10.3389/fcvm.2024.1451337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 07/31/2024] [Indexed: 09/11/2024] Open
Abstract
Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.
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Affiliation(s)
- Aashray K Gupta
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, SA, Australia
| | - Alasdair Leslie
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter Litwin
- Department of Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Brandon Stretton
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ammar Zaka
- Department of Medicine, Gold Coast University Hospital, Southport, QLD, Australia
| | - Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen Bacchi
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Jayme S Bennetts
- School of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Victorian Heart Hospital, Melbourne, NSW, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
- Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, SA, Australia
- Research, Audit and Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia
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2
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. J Am Coll Cardiol 2023; 82:1131-1174. [PMID: 37516946 DOI: 10.1016/j.jacc.2023.03.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
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3
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2023; 16:e00121. [PMID: 37499042 DOI: 10.1161/hcq.0000000000000121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
| | | | | | | | | | | | | | - Sandeep R Das
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | | | - Binita Shah
- Society for Cardiovascular Angiography and Interventions representative
| | - Nadia R Sutton
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM EVIDENCE 2023; 2:EVIDra2200322. [PMID: 38320132 DOI: 10.1056/evidra2200322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, New York
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5
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Hardiman SC, Villan Villan YF, Conway JM, Sheehan KJ, Sobolev B. Factors affecting mortality after coronary bypass surgery: a scoping review. J Cardiothorac Surg 2022; 17:45. [PMID: 35313895 PMCID: PMC8935749 DOI: 10.1186/s13019-022-01784-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded. Methods We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care. Results We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects. Conclusions Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01784-z.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 558] [Impact Index Per Article: 279.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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8
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Aspirin Reduces Ischemia-Reperfusion Injury Induced Endothelial Cell Damage of Arterial Grafts in a Rodent Model. Antioxidants (Basel) 2022; 11:antiox11020177. [PMID: 35204060 PMCID: PMC8868254 DOI: 10.3390/antiox11020177] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/11/2022] [Accepted: 01/15/2022] [Indexed: 12/10/2022] Open
Abstract
Long-term graft patency determines the prognosis of revascularization after coronary artery bypass grafting (CABG). Ischemia-reperfusion (I/R) injury of the graft suffered during harvesting and after implantation might influence graft patency. Aspirin, a nonsteroidal anti-inflammatory drug improves the long-term patency of vein grafts. Whether aspirin has the same effect on arterial grafts is questionable. We aimed to characterize the beneficial effects of aspirin on arterial bypass grafts in a rodent revascularization model. We gave Lewis rats oral pretreatment of either aspirin (n = 8) or saline (n = 8) for 5 days, then aortic arches were explanted and stored in cold preservation solution. The third group (n = 8) was a non-ischemia-reperfusion control. Afterwards the aortic arches were implanted into the abdominal aorta of recipient rats followed by 2 h of reperfusion. Endothelium-dependent vasorelaxation was examined with organ bath experiments. Immunohistochemical staining were carried out. Endothelium-dependent maximal vasorelaxation improved, nitro-oxidative stress and cell apoptosis decreased, and significant endothelial protection was shown in the aspirin preconditioned group, compared to the transplanted control group. Significantly improved endothelial function and reduced I/R injury induced structural damage were observed in free arterial grafts after oral administration of aspirin. Aspirin preconditioning before elective CABG might be beneficial on free arterial graft patency.
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10
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Calderone D, Ingala S, Mauro MS, Angiolillo DJ, Capodanno D. Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events. Expert Rev Cardiovasc Ther 2021; 19:1097-1117. [PMID: 34915778 DOI: 10.1080/14779072.2021.2020100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y12 inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention. AREAS COVERED This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD. EXPERT OPINION Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y12 inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.
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Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
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11
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Ishtiaque Al-Manzo M, DasGupta S, Biswas S, Basak B, Rahman MZ, Kumar Biswas S, Islam Talukder Q, K Chanda P, Ahmed F. Effect of Preoperative Continuation of Aspirin on Postoperative Bleeding After Off-Pump Coronary Artery Bypass Graft: A Prospective Cohort Study. Cureus 2021; 13:e18697. [PMID: 34786268 PMCID: PMC8581953 DOI: 10.7759/cureus.18697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/06/2022] Open
Abstract
Background Despite ample evidence of continuing preoperative aspirin to improve coronary artery bypass surgery outcomes, practice for the routine continuation of preoperative aspirin is inconsistent due to concern for increased postoperative bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on postoperative bleeding after off-pump coronary artery bypass grafting (OPCABG). Methodology This cohort study involved patients (n = 74) who underwent OPCABG at a single center between August 2017 and January 2018. After considering the inclusion and exclusion criteria, the patients were divided into two groups: one (n = 37) received tablet aspirin 75 mg till the day of the surgery, and for the other group (n = 37) aspirin was stopped five days before the surgery. Postoperative bleeding was recorded in both groups. After considering preoperative, intraoperative, and postoperative variables, statistical analysis was performed. Results There was no significant difference between the two groups concerning peroperative and postoperative variables. In addition, no significant difference was observed between the two groups in chest tube drainage at one, two, three, twenty-four, forty-eight, and seventy-two hours (p = 0.845, 0.126, 0.568, 0.478, 0.342, and 0.717, respectively). No significant difference was seen in the transfusion requirement of blood and fresh frozen plasma (FFP). Conclusions Continuation of preoperative aspirin till the day of the surgery is neither associated with an increase in chest tube drainage, reoperation for bleeding complications nor transfusion of blood and FFP.
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Affiliation(s)
| | - Saikat DasGupta
- Department of Cardiothoracic Surgery, Square Hospitals Limited, Dhaka, BGD
| | - Sonjoy Biswas
- Department of Cardiac Surgery, United Hospital Limited, Dhaka, BGD
| | - Bappy Basak
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, GBR
| | - Md Ziaur Rahman
- Department of Cardiac Surgery, National Heart Foundation Hospital & Research Institute, Dhaka, BGD
| | - Samir Kumar Biswas
- Department of Cardiac Surgery, National Heart Foundation Hospital & Research Institute, Dhaka, BGD
| | - Quamrul Islam Talukder
- Department of Cardiac Surgery, National Heart Foundation Hospital & Research Institute, Dhaka, BGD
| | - Prasanta K Chanda
- Department of Cardiothoracic Surgery, Square Hospitals Limited, Dhaka, BGD
| | - Farooque Ahmed
- Department of Cardiac Surgery, National Heart Foundation Hospital & Research Institute, Dhaka, BGD
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Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev 2020; 39:100619. [DOI: 10.1016/j.blre.2019.100619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
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13
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Smith ME, Finks JF. Collaborative Quality Improvement. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Kim K, Melough MM, Sakaki JR, Ha K, Marmash D, Noh H, Chun OK. Association between Urinary Cadmium to Zinc Intake Ratio with Adult Mortality in a Follow-Up Study of NHANES 1988-1994 and 1999-2004. Nutrients 2019; 12:E56. [PMID: 31878194 PMCID: PMC7019386 DOI: 10.3390/nu12010056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023] Open
Abstract
Cadmium (Cd) is a toxic heavy metal associated with increased mortality, but the effect of zinc (Zn) intake on the association between Cd and mortality is unknown. The objective of this study was to examine the association of urinary Cd to Zn intake ratio (Cd/Zn ratio) and mortality risk. In total, 15642 US adults in NHANES 1988-1994 and 1999-2004 were followed until 2011 (15-year mean follow-up). Of the 5367 total deaths, 1194 were attributed to cancer and 1677 were attributed to CVD. After adjustment for potential confounders, positive associations were observed between urinary Cd and all-cause mortality (HR for highest vs. lowest quartile: 1.38; 95% CI: 1.14-1.68) and cancer mortality (HR: 1.54; CI: 1.05-2.27). Urinary Cd was positively associated with cancer mortality among the lowest Zn consumers, and the association diminished among the highest Zn consumers. Positive relationships were observed between the Cd/Zn ratio and all-cause mortality (HR: 1.54; CI: 1.23-1.93), cancer mortality (HR: 1.65; CI: 1.11-2.47) and CVD mortality (HR: 1.49; CI: 1.18-1.88). In conclusion, these findings indicate that Zn intake may modify the association between Cd and mortality. Furthermore, the Cd/Zn ratio, which was positively associated with mortality from all causes, cancer, and CVD, may be an important predictor of mortality.
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Affiliation(s)
- Kijoon Kim
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
- Department of Food and Nutrition, Sookmyung Women’s University, Seoul 04310, Korea
| | - Melissa M. Melough
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
| | - Junichi R. Sakaki
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
| | - Kyungho Ha
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
| | - Dalia Marmash
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
| | - Hwayoung Noh
- Nutritional Methodology and Biostatistics Group, Section of Nutrition and Metabolism, International Agency for Research on Cancer(IARC-WHO), 69372 Lyon, France;
| | - Ock K. Chun
- Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; (K.K.); (M.M.M.); (J.R.S.); (K.H.); (D.M.)
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15
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Wang W, Wang Y, Piao H, Li B, Wang T, Li D, Zhu Z, Xu R, Liu K. Early Outcomes of Low Postoperative Bleeding after Off-Pump Coronary Artery Bypass Grafting. Braz J Cardiovasc Surg 2019; 34:412-419. [PMID: 31454195 PMCID: PMC6713362 DOI: 10.21470/1678-9741-2018-0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective To investigate whether low bleeding influences the early outcomes after
off-pump coronary artery bypass grafting (CABG). Methods Retrospective analysis of ischemic heart disease patients who underwent
off-pump CABG from January 2013 to December 2017. Patients were divided into
low-bleeding group (n=659) and bleeding group (n=270), according to total
drainage from chest tube during the first postoperative 12 hours. Clinical
material and early outcomes were compared between the groups. Results Baseline was similar in the two groups. Operation time was 270±51 min
in the low-bleeding group and 235±46 min in the bleeding group
(P<0.0001). The low-bleeding group presented smaller
drainage during the first 12 h (237±47 ml) and shorter mechanical
ventilation time (6.86±3.78 h) than the bleeding group
(557±169 ml and 10.66±5.19 h, respectively)
(P<0.0001). Hemodynamic status was more stable in
the low-bleeding group (P<0.0001) and usage rate of more
than two vasoactive agents in this group was lower than in the bleeding
group (P<0.0001). Number of distal anastomosis,
reoperation for bleeding, suddenly increase in chest tube output, intensive
care unit (ICU) stay, hospital stay, and other early outcomes had no
statistical significance between the groups
(P>0.05). Conclusion Postoperative bleeding < 300 ml/12 h in off-pump CABG patients did not
require blood product transfusion and reoperation and that would contribute
to reduction in mechanical ventilation time and maintaining hemodynamic
stability. Bleeding < 800 ml during the first postoperative 12 h did not
increase infection rates and ICU length of stay.
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Affiliation(s)
- Weitie Wang
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Yong Wang
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Hulin Piao
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Bo Li
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Tiance Wang
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Dan Li
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Zhicheng Zhu
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Rihao Xu
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
| | - Kexiang Liu
- Jilin University 2nd Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin China Department of Cardiovascular Surgery, 2nd Hospital of Bethune, Jilin University, Changchun, Jilin, China
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Gupta S, Belley-Cote EP, Agahi P, Basha A, Jaffer I, Mehta S, Schwalm JD, Whitlock RP. Antiplatelet Therapy and Coronary Artery Bypass Grafting: Analysis of Current Evidence With a Focus on Acute Coronary Syndrome. Can J Cardiol 2019; 35:1030-1038. [DOI: 10.1016/j.cjca.2019.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 01/31/2023] Open
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Abstract
PURPOSE OF REVIEW Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. RECENT FINDINGS The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.
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Affiliation(s)
- Bennet George
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, 900 S. Limestone Street, 326 Wethington Bldg, Lexington, KY, 40536-0200, USA.
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18
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Hwang D, Lee JM, Rhee TM, Kim YC, Park J, Park J, Ahn C, Song YB, Hahn JY, Kim KB, Lee YT, Koo BK. The Effects of Preoperative Aspirin on Coronary Artery Bypass Surgery: a Systematic Meta-Analysis. Korean Circ J 2019; 49:498-510. [PMID: 30891961 PMCID: PMC6554592 DOI: 10.4070/kcj.2018.0296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/24/2018] [Accepted: 01/15/2019] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives Aspirin plays an important role in the maintenance of graft patency and the prevention of thrombotic event after coronary artery bypass graft surgery (CABG). However, the use of preoperative aspirin is still under debate due to the risk of bleeding. Methods From PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, data were extracted by 2 independent reviewers. Meta-analysis using random effect model was performed. Results We performed a systemic meta-analysis of 17 studies (12 randomized controlled studies and 5 non-randomized registries) which compared clinical outcomes of 9,101 patients who underwent CABG with or without preoperative aspirin administration. Preoperative aspirin increased chest tube drainage (weighted mean difference 177.4 mL, 95% confidence interval [CI], 41.3–313.4; p=0.011). However, the risk of re-operation for bleeding was not different between the preoperative aspirin group and the control group (3.2% vs. 2.4%; odds ratio [OR], 1.23; 95% CI, 0.94–1.60; p=0.102). There was no difference in the rates of all-cause mortality (1.6% vs. 1.5%; OR, 0.98; 95% CI, 0.64–1.49; p=0.920) and myocardial infarction (MI) (8.7% vs. 10.4%; OR, 0.83; 95% CI, 0.66–1.04; p=0.102) between patients with and without preoperative aspirin administration. Conclusions Although aspirin increased the amount of chest tube drainage, it was not associated with increased risk of re-operation for bleeding. In addition, the risks of early postoperative all-cause mortality and MI were not reduced by using preoperative aspirin.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Joo Myung Lee
- Department of Internal Medicine and Cardiovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Young Chan Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Chul Ahn
- Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, USA
| | - Young Bin Song
- Department of Internal Medicine and Cardiovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Yong Hahn
- Department of Internal Medicine and Cardiovascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Bon Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.,Institute of Aging, Seoul National University, Seoul, Korea.
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Akonjom M, Battenberg A, Beverland D, Choi JH, Fillingham Y, Gallagher N, Han SB, Jang WY, Jiranek W, Manrique J, Mihov K, Molloy R, Mont MA, Nandi S, Parvizi J, Peel T, Pulido L, Sarungi M, Sodhi N, Alberdi MT, Olivan RT, Wallace D, Weng X, Wynn-Jones H, Yeo SJ. General Assembly, Prevention, Blood Conservation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S147-S155. [PMID: 30348569 DOI: 10.1016/j.arth.2018.09.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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20
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Perioperative aspirin and long-term survival in patients undergoing coronary artery bypass graft. Sci Rep 2018; 8:17051. [PMID: 30451948 PMCID: PMC6242822 DOI: 10.1038/s41598-018-35208-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 10/31/2018] [Indexed: 01/13/2023] Open
Abstract
This study aimed to examine association between perioperative uses of aspirin and long-term survival in patients undergoing CABG. A retrospective cohort study was performed in 9,584 consecutive patients receiving cardiac surgery from three tertiary hospitals. Of all the patients, 4,132 patients undergoing CABG met inclusion criteria and were divided into four groups: with or without preoperative or postoperative aspirin respectively. 30-day postoperative and long-term mortality were compared with the use of propensity scores and inverse probability weighting adjustment to reduce the treatment-selection bias. The patients taking preoperative aspirin presented significantly more with comorbidities. However, the results of this study showed that preoperative aspirin (vs. no preoperative aspirin) was associated with significantly reduced the risk of 30-day mortality in the patients undergoing CABG. Further, the results of long-term mortality showed that the patients taking preoperative aspirin and postoperative aspirin (vs. not taking) were associated with significantly reduced the risk of 4-year mortality (14.8% vs. 18.1%, RR: 0.82, 95% CI: 0.75–0.89, P = 0.005; 10.7% vs. 16.2%, RR: 0.66, 95% CI: 0.50–0.82, P = 0.003). In conclusion, this cohort study showed that perioperative (before and after surgery) use of aspirin was associated with significant reduction in 30-day mortality without significant bleeding complications, also improved long-term survival in patients undergoing CABG.
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21
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Lomivorotov VV, Efremov SM, Abubakirov MN, Belletti A, Karaskov AM. Perioperative Management of Cardiovascular Medications. J Cardiothorac Vasc Anesth 2018; 32:2289-2302. [DOI: 10.1053/j.jvca.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Indexed: 12/28/2022]
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22
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Solo K, Lavi S, Choudhury T, Martin J, Nevis IF, Kwok CS, Kotronias RA, Nishina N, Sponga S, Ayan D, Tzemos N, Mamas MA, Bagur R. Pre-operative use of aspirin in patients undergoing coronary artery bypass grafting: a systematic review and updated meta-analysis. J Thorac Dis 2018; 10:3444-3459. [PMID: 30069340 DOI: 10.21037/jtd.2018.05.187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Aspirin therapy improves saphenous vein graft (SVG) patency in patients undergoing coronary artery bypass graft (CABG), however, its use in the pre-operative period remains controversial. Therefore, we conducted a systematic review and meta-analysis of randomized-controlled trials (RCTs) to update the evidence about risk and benefits of pre-operative aspirin therapy in patients undergoing CABG. Methods Electronic databases (Medline, Embase, PubMed, Cochrane Library, and Scopus) were searched to identify RCTs evaluating the effect of aspirin versus placebo/control before CABG. Two investigators independently and in duplicate screened citations and extracted data and rated the risk of bias. The strength of evidence was appraised using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Meta-analysis was performed using a random-effects model. The main outcomes of interest were 30-day mortality, peri-operative myocardial infarction (MI), chest tube drainage and SVG occlusion. Results A total of 13 RCTs involving 4,377 participants (2,266/2,111 pre-operative aspirin/control) met the inclusion criteria. Pre-operative aspirin reduced the risk of SVG occlusion [risk ratio (RR): 0.69, 95% confidence interval (CI): 0.49-0.97, P=0.03, I2=16%], but no differences in mortality (RR: 1.41, 95% Cl: 0.73-2.74, I2=0%) and MI (RR: 0.84, 95% CI: 0.69-1.03, I2=0%) were found. However, pre-operative aspirin increased chest tube drainage (MD: 100.40 mL, 95% CI: 24.32-176.47 mL, P=0.01, I2=84%) and surgical re-exploration (RR: 1.52, 95% CI: 1.02-2.27, P=0.04, I2=8%), with no significant difference in RBC transfusion (RR: 1.06, 95% CI: 0.90-1.25, I2=35%). Conclusions Based on trials where the rated body of evidence was of low to very-low quality, pre-operative aspirin improves SVG patency but increases chest tube drainage and need for surgical re-exploration.
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Affiliation(s)
- Karla Solo
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Shahar Lavi
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Janet Martin
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,Department of Anesthesia & Perioperative Medicine, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK
| | - Rafail A Kotronias
- Oxford University Clinical Academic Graduate School, Oxford University, Oxford, UK
| | - Natsumi Nishina
- Faculty of International Communication, Gunma Prefectural Women's University, Tamamura, Gunma, Japan
| | - Sandro Sponga
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Diana Ayan
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.,London Health Sciences Centre, London, Ontario, Canada.,Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, UK
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Abstract
PURPOSE OF REVIEW Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field. RECENT FINDINGS Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation. SUMMARY Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.
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Solo K, Martin J, Lavi S, Kabali C, John-Baptiste A, Nevis IF, Choudhury T, Mamas MA, Bagur R. Antithrombotic therapy in patients receiving saphenous vein coronary artery bypass grafts: a protocol for a systematic review and network meta-analysis. BMJ Open 2018; 8:e019555. [PMID: 29627809 PMCID: PMC5892747 DOI: 10.1136/bmjopen-2017-019555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The current evidence for the prevention of saphenous vein graft failure (SVGF) after coronary artery bypass graft (CABG) surgery consists of direct head-to-head comparison of treatments (including placebo) in randomised-controlled trials (RCTs) and observational studies. However, summarising the evidence using traditional pairwise meta-analyses does not allow the inclusion of data from treatments that have not been compared head to head. Exclusion of such comparisons could impact the precision of pooled estimates in a meta-analysis. Hence, to address the challenge of whether aspirin alone or in addition to another antithrombotic agent is a more effective regimen to improve SVG patency, a network meta-analysis (NMA) is necessary. The objectives of this study are to synthesise the available evidence on antithrombotic agents (or their combination) and estimate the treatment effects among direct and indirect treatment comparisons on SVGF and major adverse cardiovascular events, and to generate a treatment ranking according to their efficacy and safety outcomes. METHODS We will perform a systematic review of RCTs evaluating antithrombotic agents in patients undergoing CABG. A comprehensive English literature search will be conducted using electronic databases and grey literature resources to identify published and unpublished articles. Two individuals will independently and in duplicate screen potential studies, assess the eligibility of potential studies and extract data. Risk of bias and quality of evidence will also be evaluated independently and in duplicate. We will investigate the data to ensure its suitability for NMA, including adequacy of the outcome data and transitivity of treatment effects. We plan to estimate the pooled direct, indirect and the mixed effects for all antithrombotic agents using a NMA. ETHICS AND DISSEMINATION Due to the nature of the study, there are no ethical concerns nor informed consent required. We anticipate that this NMA will be the first to simultaneously assess the relative effects of multiple antithrombotic agents in patients undergoing CABG. The results of this NMA will inform clinicians, patients and guideline developers the best available evidence on comparative effects benefits of antithrombotic agents after CABG while considering the side effect profile to support future clinical decision-making. We will disseminate the results of our systematic review and NMA through a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017065678.
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Affiliation(s)
- Karla Solo
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Janet Martin
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Anesthesia and Perioperative Medicine, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
| | - Shahar Lavi
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Conrad Kabali
- Epidemiology Division, University of Toronto, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Ava John-Baptiste
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Anesthesia and Perioperative Medicine, Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
- Interfaculty Program in Public Health, Western University, London, Ontario, Canada
| | | | - Tawfiq Choudhury
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Keele, UK
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Division of Cardiology, London Health Sciences Centre, London, Ontario, Canada
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Keele, UK
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25
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Therapeutic Advances in the Perioperative Period for Older Adults. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M, Marquis-Gravel G, Robinson SD, Sibbald M, So DY, Wong GC, Abunassar JG, Ackman ML, Bell AD, Cartier R, Douketis JD, Lawler PR, McMurtry MS, Udell JA, van Diepen S, Verma S, Mancini GBJ, Cairns JA, Tanguay JF. 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2017; 34:214-233. [PMID: 29475527 DOI: 10.1016/j.cjca.2017.12.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.
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Affiliation(s)
- Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kevin R Bainey
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Warren J Cantor
- University of Toronto and Southlake Regional Health Centre, Toronto, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | | | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Matthew Sibbald
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graham C Wong
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Margaret L Ackman
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Alan D Bell
- University of Toronto, Toronto, Ontario, Canada
| | - Raymond Cartier
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | - James D Douketis
- McMaster University and St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Patrick R Lawler
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael S McMurtry
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jacob A Udell
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean van Diepen
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Subodh Verma
- University of Toronto and St Michael's Hospital, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John A Cairns
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jean-François Tanguay
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada.
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Gruzdeva O, Uchasova E, Fanaskova E, Akbasheva O, Penskaya T, Plotnikov G, Dyleva Y, Barbarash O. Use of thrombin generation test for monitoring hemostasis in coronary bypass surgery. Clin Hemorheol Microcirc 2017; 66:57-66. [PMID: 28128747 PMCID: PMC5438468 DOI: 10.3233/ch-160216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To evaluate the parameters of the thrombin generation test (TGT) in coronary artery disease (CAD) patients on prolonged aspirin therapy during on-pump coronary artery bypass grafting (CABG) after donor platelet concentrate transfusion. A total of 148 patients with CAD on prolonged aspirin therapy (75–100 mg/day) who have undergone elective on-pump CABG were consecutively included in the study. Patients were divided randomly into two groups. Group 1 (n = 76) received donor platelet transfusions after cardiopulmonary bypass, whereas Group 2 (n = 72) did not. TGT parameters were measured using an analyzer at pre-, intra-, and early postoperative periods. Activation of the endogenous thrombin potential was observed in patients on prolonged aspirin therapy in the pre- and intraoperative periods, as confirmed by high peak thrombin and increased velocity index. The activation time of the prothrombinase complex and thrombin generation time were greater than the control group. The blood hemostatic potential in patients who did not receive transfusions in the early postoperative period decreased up to the level of the control group in the extended time parameters. Hemostatic potential in plasma in patients on aspirin was preserved. Given the laboratory test results and clinical data, platelet concentrate transfusion is unnecessary for prevention.
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Affiliation(s)
- Olga Gruzdeva
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Evgenya Uchasova
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Elena Fanaskova
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Olga Akbasheva
- Federal State Budget Educational Institution of Higher Professional Education "Siberian StateMedical University", the Ministry of Health of the Russian Federation, Tomsk, Russia
| | - Tatyana Penskaya
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Georgy Plotnikov
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Yulia Dyleva
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia
| | - Olga Barbarash
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Diseases", Kemerovo, Russia.,Federal State Budget Educational Institution of Higher Professional Education "Kemerovo State Medical University", the Ministry of Health of the Russian Federation, Kemerovo, Russia
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28
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Goldhammer JE, Herman CR, Berguson MW, Torjman MC, Epstein RH, Sun JZ. Preoperative Aspirin Does Not Increase Transfusion or Reoperation in Isolated Valve Surgery. J Cardiothorac Vasc Anesth 2017; 31:1618-1623. [DOI: 10.1053/j.jvca.2017.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Indexed: 11/11/2022]
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Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN, Badimon L, Vranckx P, Agewall S, Andreotti F, Antman E, Barbato E, Bassand JP, Bugiardini R, Cikirikcioglu M, Cuisset T, De Bonis M, Delgado V, Fitzsimons D, Gaemperli O, Galiè N, Gilard M, Hamm CW, Ibanez B, Iung B, James S, Knuuti J, Landmesser U, Leclercq C, Lettino M, Lip G, Piepoli MF, Pierard L, Schwerzmann M, Sechtem U, Simpson IA, Uva MS, Stabile E, Storey RF, Tendera M, Van de Werf F, Verheugt F, Aboyans V. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg 2017; 53:34-78. [DOI: 10.1093/ejcts/ezx334] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN, Badimon L, Vranckx P, Agewall S, Andreotti F, Antman E, Barbato E, Bassand JP, Bugiardini R, Cikirikcioglu M, Cuisset T, De Bonis M, Delgado V, Fitzsimons D, Gaemperli O, Galiè N, Gilard M, Hamm CW, Ibanez B, Iung B, James S, Knuuti J, Landmesser U, Leclercq C, Lettino M, Lip G, Piepoli MF, Pierard L, Schwerzmann M, Sechtem U, Simpson IA, Uva MS, Stabile E, Storey RF, Tendera M, Van de Werf F, Verheugt F, Aboyans V, Windecker S, Aboyans V, Agewall S, Barbato E, Bueno H, Coca A, Collet JP, Coman IM, Dean V, Delgado V, Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P, Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh T, Piepoli MF, Ponikowski P, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Zamorano JL, Windecker S, Aboyans V, Agewall S, Barbato E, Bueno H, Coca A, Collet JP, Coman IM, Dean V, Delgado V, Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P, Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh T, Piepoli MF, Ponikowski P, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Zamorano JL, Roithinger FX, Aliyev F, Stelmashok V, Desmet W, Postadzhiyan A, Georghiou GP, Motovska Z, Grove EL, Marandi T, Kiviniemi T, Kedev S, Gilard M, Massberg S, Alexopoulos D, Kiss RG, Gudmundsdottir IJ, McFadden EP, Lev E, De Luca L, Sugraliyev A, Haliti E, Mirrakhimov E, Latkovskis G, Petrauskiene B, Huijnen S, Magri CJ, Cherradi R, Ten Berg JM, Eritsland J, Budaj A, Aguiar CT, Duplyakov D, Zavatta M, Antonijevic NM, Motovska Z, Fras Z, Montoliu AT, Varenhorst C, Tsakiris D, Addad F, Aydogdu S, Parkhomenko A, Kinnaird T. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J 2017; 39:213-260. [DOI: 10.1093/eurheartj/ehx419] [Citation(s) in RCA: 1697] [Impact Index Per Article: 242.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Lee AT, Gagnidze A, Pan SR, Sookplung P, Nair B, Newman SF, Ben-Ari A, Zaky A, Cain K, Vavilala MS, Rozet I. Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients. Anesth Analg 2017; 125:514-520. [DOI: 10.1213/ane.0000000000002053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Mazzeffi MA, Lee K, Taylor B, Tanaka KA. Perioperative management and monitoring of antiplatelet agents: a focused review on aspirin and P2Y 12 inhibitors. Korean J Anesthesiol 2017; 70:379-389. [PMID: 28794832 PMCID: PMC5548939 DOI: 10.4097/kjae.2017.70.4.379] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/02/2023] Open
Abstract
Platelets play pivotal roles in hemostasis as well as pathological arterial thrombosis. The combination of aspirin and a P2Y12 inhibitor has become the mainstay therapy in the ageing population with cardiovascular conditions, particularly during and after percutaneous coronary intervention. A number of novel P2Y12 inhibitors has become available in the recent years, and they markedly vary in pharmacokinetic and pharmacodynamic properties. Perioperative physicians today face a challenge of preventing hemorrhage due to platelet inhibitors, while minimizing thrombotic risks. There are several point-of-care platelet function tests available in the peri-procedural assessment of residual platelet aggregation. However, these platelet function tests are not standardized in terms of sample processing, agonist type and potency as well as methods of detecting platelet activity. Understanding the differences in pharmacological properties of antiplatelet agents, principles of platelet function tests, and pertinent hemostatic strategies may be useful to anesthesiologists and intensivists who manage perioperative issues associated with antiplatelet agents. The objectives of this review are: 1) to discuss clinical data on aspirin and P2Y12 inhibitors relating to perioperative bleeding, 2) to outline different features of point-of-care platelet function tests, and 3) to discuss therapeutic options for the prevention and treatment of bleeding associated with antiplatelet agents.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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McKavanagh P, Yanagawa B, Zawadowski G, Cheema A. Management and Prevention of Saphenous Vein Graft Failure: A Review. Cardiol Ther 2017; 6:203-223. [PMID: 28748523 PMCID: PMC5688971 DOI: 10.1007/s40119-017-0094-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 12/16/2022] Open
Abstract
Coronary artery bypass grafting (CABG) remains a vital treatment for patients with multivessel coronary artery disease (CAD), especially diabetics. The long-term benefit of the internal thoracic artery graft is well established and remains the gold standard for revascularization of severe CAD. It is not always possible to achieve complete revascularization through arterial grafts, necessitating the use of saphenous vein grafts (SVG). Unfortunately, SVGs do not have the same longevity, and their failure is associated with significant adverse cardiac outcomes and mortality. This paper reviews the pathogenesis of SVG failure, highlighting the difference between early, intermediate, and late failure. It also addresses the different surgical techniques that affect the incidence of SVG failure, as well as the medical and percutaneous prevention and treatment options in contemporary practice.
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Affiliation(s)
- Peter McKavanagh
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Bobby Yanagawa
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - George Zawadowski
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Asim Cheema
- Terrence Donnelly Heart Center, Divisions of Cardiology and Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
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Lee J, Jung CW, Jeon Y, Kim TK, Cho YJ, Koo CH, Choi YH, Kim KB, Hwang HY, Kim HR, Park JY. Effects of preoperative aspirin on perioperative platelet activation and dysfunction in patients undergoing off-pump coronary artery bypass graft surgery: A prospective randomized study. PLoS One 2017; 12:e0180466. [PMID: 28715503 PMCID: PMC5513419 DOI: 10.1371/journal.pone.0180466] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022] Open
Abstract
The benefit of aspirin use after coronary artery bypass graft surgery has been well proven. However, the effect of preoperative aspirin use in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) has not been evaluated sufficiently. To evaluate platelet function changes during OPCAB due to preoperative aspirin use, we conducted a randomized controlled trial using flow cytometry and the Multiplate® analyzer. Forty-eight patients scheduled for elective OPCAB were randomized to the aspirin continuation (100 mg/day until operative day) and discontinuation (4 days before the operative day) groups. Platelet function was measured using the platelet activation markers CD62P, CD63, and PAC-1 by flow cytometry, and platelet aggregation was measured using the Multiplate® analyzer, after the induction of anesthesia (baseline), at the end of the operation, and 24 and 48 h postoperatively. Findings of conventional coagulation assays, thromboelastography by ROTEM® assays, and postoperative bleeding—related clinical outcomes were compared between groups. No significant change in CD62P, CD63, or PAC-1 was observed at the end of the operation or 24 or 48 h postoperatively compared with baseline in either group. The area under the curve for arachidonic acid—stimulated platelet aggregation, measured by the Multiplate® analyzer, was significantly smaller in the aspirin continuation group (P < 0.01). However, chest tube drainage and intraoperative and postoperative transfusion requirements did not differ between groups. Our study showed that preoperative use of aspirin for OPCAB did not affect perioperative platelet activation, but it impaired platelet aggregation, which did not affect postoperative bleeding, by arachidonic acid.
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Affiliation(s)
- Jiwon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- * E-mail:
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yoon Hyeong Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hang-Rae Kim
- Department of Anatomy and Cell Biology, Department of Biomedical Sciences, BK21 Plus Biomedical Science Project, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Young Park
- FACS Core Facility, Seoul National University College of Medicine, Seoul, Korea
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Goldhammer JE, Herman CR, Sun JZ. Perioperative Aspirin in Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1060-1070. [DOI: 10.1053/j.jvca.2016.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Indexed: 01/09/2023]
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Preoperative aspirin use and acute kidney injury after cardiac surgery: A propensity-score matched observational study. PLoS One 2017; 12:e0177201. [PMID: 28472145 PMCID: PMC5417712 DOI: 10.1371/journal.pone.0177201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The association between preoperative aspirin use and postoperative acute kidney injury (AKI) in cardiovascular surgery is unclear. We sought to evaluate the effect of preoperative aspirin use on postoperative AKI in cardiac surgery. METHODS A total of 770 patients who underwent cardiovascular surgery under cardiopulmonary bypass were reviewed. Perioperative clinical parameters including preoperative aspirin administration were retrieved. We matched 108 patients who took preoperative aspirin continuously with patients who stopped aspirin more than 7 days or did not take aspirin for the month before surgery. The parameters used in the matching included variables related to surgery type, patient's demographics, underlying medical conditions and preoperative medications. RESULTS In the first seven postoperative days, 399 patients (51.8%) developed AKI, as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria and 128 patients (16.6%) required hemodialysis. Most patients took aspirin 100 mg once daily (n = 195, 96.5%) and the remaining 75 mg once daily. Multivariable analysis showed that preoperative maintenance of aspirin was independently associated with decreased incidence of postoperative AKI (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.98, P = 0.048; after propensity score matching: OR 0.39, 95% CI 0.22-0.67, P = 0.001). Preoperative maintenance of aspirin was associated with less incidence of AKI defined by KDIGO both in the entire and matched cohort (n = 44 [40.7%] vs. 69 [63.9%] in aspirin and non-aspirin group, respectively in matched sample, relative risk [RR] 0.64, 95% CI 0.49, 0.83, P = 0.001). Preoperative aspirin was associated with decreased postoperative hospital stay after matching (12 [9-18] days vs. 16 [10-25] in aspirin and non-aspirin group, respectively, P = 0.038). Intraoperative estimated or calculated blood loss using hematocrit difference and estimated total blood volume showed no difference according to aspirin administration in both entire and matched cohort. CONCLUSIONS Preoperative low dose aspirin administration without discontinuation was protective against postoperative AKI defined by KDIGO criteria independently in both entire and matched cohort. Preoperative aspirin was also associated with decreased hemodialysis requirements and decreased postoperative hospital stay without increasing bleeding. However, differences in AKI and hospital stay were not associated with in-hospital mortality.
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Elbadawi A, Saad M, Nairooz R. Aspirin Use Prior to Coronary Artery Bypass Grafting Surgery: a Systematic Review. Curr Cardiol Rep 2017; 19:18. [DOI: 10.1007/s11886-017-0822-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hansson EC, Jeppsson A. Platelet inhibition and bleeding complications in cardiac surgery: A review. SCAND CARDIOVASC J 2016; 50:349-354. [DOI: 10.1080/14017431.2016.1231935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Emma C. Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Kashani R, Bowles C, Sareh S, Toppen W, Ou R, Shemin R, Benharash P. Use of preoperative aspirin in combined coronary and valve operations. Surgery 2016; 160:1612-1618. [PMID: 27590618 DOI: 10.1016/j.surg.2016.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/17/2016] [Accepted: 07/23/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to determine the relationship between preoperative aspirin use and postoperative outcomes in patients undergoing combined coronary artery bypass grafting and valve operations. METHODS All combined coronary artery bypass grafting and valve procedures from 2008 to 2015 at our institution were identified. After exclusions, patients were stratified according to those that received preoperative aspirin and those who did not. Propensity score methodology was used to match the 2 groups using baseline and operative characteristics. Logistic regression models were then developed to assess differences in postoperative outcomes between groups. RESULTS Of the 563 patients identified, 534 met inclusion criteria: preoperative aspirin = 327 (61.2%), no preoperative aspirin = 207 (38.8%). After propensity matching, 194 patient pairs were analyzed, with no significant differences in preoperative characteristics. No significant differences were observed between the preoperative aspirin and no preoperative aspirin groups in rates of 30-day mortality (3.6% vs 4.1%, P = 1.00), major adverse cardiovascular events (23.2% vs 24.2%, P = .91), or 30-day readmission (12.4% vs 11.9%, P = 1.00), among others. CONCLUSION Preoperative aspirin use in patients undergoing combined coronary artery bypass grafting and valve operations was not associated with significant differences in major postoperative outcomes. Large-scale, randomized trials are needed to better establish the role of preoperative aspirin in this population.
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Affiliation(s)
- Rustin Kashani
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Cayley Bowles
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Sohail Sareh
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - William Toppen
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Ryan Ou
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Richard Shemin
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA.
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Nugent WC. Building and Supporting Sustainable Improvement in Cardiac Surgery: The Northern New England Experience. Semin Cardiothorac Vasc Anesth 2016; 9:115-8. [PMID: 15920634 DOI: 10.1177/108925320500900202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Northern New England Cardiovascular Disease Study Group (NNECDSG) was formed as a regional clinical database that would allow clinicians to track outcomes after cardiac interventions. The purpose of the NNECDSG would be to use its database and organizational structure to seek best practices and disseminate information aimed at improving results for patients undergoing cardiovascular interventions. Since 1987, this voluntary regional collaborative of clinicians, hospital administrators, and health care research personnel has tracked consecutive cardiovascular interventions performed throughout Northern New England and reported its findings to the clinicians. Collaboration between NNECDSG institutions has led to progressive refinements in the clinical database, institutional site visits, efforts to understand and standardize ideal processes of care, risk-stratification tools to aid in decision making, and most recently, tools to track and report on appropriateness of interventions based on national criteria. As a result of these efforts, mortality rates after coronary bypass graft surgery have steadily declined and the variation in mortality rates between institutions has disappeared.
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Affiliation(s)
- William C Nugent
- Section of Cardiothoracic Surgery, Darthmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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41
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Curl K, LeBude B, Ruggiero N, Fischman D, Rose A, Patel S, Ogilby D, Walinsky P, Jasti B, Savage M. Frequency of Use of Statins and Aspirin in Patients With Previous Coronary Artery Bypass Grafting. Am J Cardiol 2016; 118:40-3. [PMID: 27178330 DOI: 10.1016/j.amjcard.2016.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/12/2016] [Accepted: 04/12/2016] [Indexed: 11/16/2022]
Abstract
Coronary artery bypass grafting (CABG) is commonly performed to treat ischemic heart disease, but long-term benefits are limited by failed patency of bypass grafts. Both statin medications and aspirin hold class I indications for all post-CABG patients and should be continued indefinitely unless contraindications exist. Unfortunately, there are limited data regarding long-term usage of these essential medications. We assessed the utilization rates of statins and aspirin among post-CABG patients referred for coronary angiography. Analysis of post-CABG patients presenting to Thomas Jefferson University for a cardiac catheterization procedure at least 3 years after surgery was performed. Inpatient and outpatient records were reviewed to assess prescribing patterns of these medications, as well as other pertinent clinical and laboratory data. The study population was 381 consecutive patients presenting at a mean of 11 ± 6 years from CABG. Mean age was 69 ± 11 years and 78% were men. A total 67% of patients were being prescribed a statin, whereas 75% were prescribed aspirin. Only 52% were prescribed both at the time of catheterization. Patients prescribed a statin had a significantly lower mean low-density lipoprotein (87 vs 106 [p <0.01]) and total cholesterol values (151 vs 162 [p <0.01]). A total of 35% of patients had low-density lipoprotein ≥100. Only 43% of saphenous vein grafts in the patients not on statin medications remained patent. In conclusion, long-term statin and aspirin use after CABG remains suboptimal despite clear guideline recommendations and clinical trial evidence of their effectiveness.
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Affiliation(s)
- Kevin Curl
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Bryan LeBude
- Division of Cardiology, Department of Medicine, Washington Hospital Center, Georgetown University Hospital, Washington, DC
| | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - David Fischman
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew Rose
- Department of Cardiology, Pottstown Medical Associates, Pottstown, Pennsylvania
| | - Sulay Patel
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
| | - David Ogilby
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Paul Walinsky
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Babu Jasti
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael Savage
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Dyke CM, Jennings LK, Maier G, Andreou C, Daly R, Tamberella MR. Preoperative Platelet Inhibition With Eptifibatide During Coronary Artery Bypass Grafting With Cardiopulmonary Bypass. J Cardiovasc Pharmacol Ther 2016; 12:54-60. [PMID: 17495258 DOI: 10.1177/1074248406299068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Platelet glycoprotein IIb-IIIa antagonists reduce cardiac events in acute coronary syndromes (ACSs), but their use is limited during coronary artery bypass grafting (CABG) because of bleeding concerns. Patients with ACS, however, are at increased risk for cardiac events after CABG. The use of short-acting glycoprotein IIbIIIa inhibitor eptifibatide in patients with ACS undergoing CABG was investigated. Fifteen patients with ACS and undergoing CABG with cardiopulmonary bypass were enrolled. One withdrew before surgery. Patients received heparin and eptifibatide preoperatively. Eptifibatide concentration and receptor occupancy (RO) at termination of infusion were similar in the two groups. Immediately before surgery, eptifibatide levels in the 2-hour group were twice that in the 4-hour group, and platelet RO was higher. Cessation of eptifibatide 4 hours before surgery results in less bleeding and transfusions than 2 hours before surgery. The optimal balance between bleeding and platelet inhibition is approximately 60% platelet RO. Further investigation of upstream therapy should target this threshold.
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Affiliation(s)
- Cornelius M Dyke
- Carolina Cardiovascular and Thoracic Surgery Associates, Gaston Memorial Hospital, 2555 Court Drive, Gastonia, NC 28043, USA.
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Gaudino M, Di Franco A, Crea F, Girardi LN. Secondary prevention for CABG patients: take two arterial grafts at the time of your coronary operation. J Thorac Dis 2016; 8:1057-9. [PMID: 27293818 DOI: 10.21037/jtd.2016.04.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mario Gaudino
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Antonino Di Franco
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Filippo Crea
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Leonard N Girardi
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
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[Comment on: Acetylsalicylic acid before coronary surgery: Black, white or grey at least?]. Anaesthesist 2016; 65:710-1. [PMID: 27287403 DOI: 10.1007/s00101-016-0191-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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45
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Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, Wallace S. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med 2016; 374:728-37. [PMID: 26933848 DOI: 10.1056/nejmoa1507688] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most patients with coronary artery disease receive aspirin for primary or secondary prevention of myocardial infarction, stroke, and death. Aspirin poses a risk of bleeding in patients undergoing surgery, but it is unclear whether aspirin should be stopped before coronary artery surgery. METHODS We used a 2-by-2 factorial trial design to randomly assign patients who were scheduled to undergo coronary artery surgery and were at risk for perioperative complications to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin trial are reported here. Patients were randomly assigned to receive 100 mg of aspirin or matched placebo preoperatively. The primary outcome was a composite of death and thrombotic complications (nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days after surgery. RESULTS Among 5784 eligible patients, 2100 were enrolled; 1047 were randomly assigned to receive aspirin and 1053 to receive placebo. A primary outcome event occurred in 202 patients in the aspirin group (19.3%) and in 215 patients in the placebo group (20.4%) (relative risk, 0.94; 95% confidence interval, 0.80 to 1.12; P=0.55). Major hemorrhage leading to reoperation occurred in 1.8% of patients in the aspirin group and in 2.1% of patients in the placebo group (P=0.75), and cardiac tamponade occurred at rates of 1.1% and 0.4%, respectively (P=0.08). CONCLUSIONS Among patients undergoing coronary artery surgery, the administration of preoperative aspirin resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than that with placebo. (Funded by the Australian National Health and Medical Research Council and others; Australia New Zealand Clinical Trials Registry number, ACTRN12605000557639.).
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Affiliation(s)
- Paul S Myles
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Julian A Smith
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Andrew Forbes
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Brendan Silbert
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Mohandas Jayarajah
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Thomas Painter
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - D James Cooper
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Silvana Marasco
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - John McNeil
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Jean S Bussières
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
| | - Sophie Wallace
- From the Alfred Hospital (P.S.M., D.J.C, S.M., S.W.) and Monash University (P.S.M., J.A.S., A.F., D.J.C., S.M., J.M.), Melbourne, VIC, St. Vincent's Hospital, Fitzroy, VIC (B.S.), and the Royal Adelaide Hospital, Adelaide, SA (T.P.) - all in Australia; Plymouth Medical School, Devon, United Kingdom (M.J.); and Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada (J.S.B)
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Association Between Preoperative Aspirin-dosing Strategy and Mortality After Coronary Artery Bypass Graft Surgery. Ann Surg 2015; 262:1150-6. [DOI: 10.1097/sla.0000000000000951] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Dundon JM, Trimba R, Bree KJ, Woods CJ, Laughlin RT. Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Rev 2015; 3:01874474-201509000-00002. [PMID: 27490669 DOI: 10.2106/jbjs.rvw.n.00105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- John M Dundon
- Department of Orthopaedic Surgery, Sports Medicine & Rehabilitation, Boonshoft School of Medicine, Wright State University, 30 East Apple Street, Suite 2200, Dayton, OH 45409
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Hastings S, Myles P, McIlroy D. Aspirin and coronary artery surgery: a systematic review and meta-analysis. Br J Anaesth 2015; 115:376-85. [DOI: 10.1093/bja/aev164] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Goldhammer JE, Marhefka GD, Daskalakis C, Berguson MW, Bowen JE, Diehl JT, Sun J. The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery. PLoS One 2015; 10:e0134670. [PMID: 26230605 PMCID: PMC4521851 DOI: 10.1371/journal.pone.0134670] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/13/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin's anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery. METHODS This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets. RESULTS No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets. CONCLUSIONS In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.
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Affiliation(s)
- Jordan E. Goldhammer
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Gregary D. Marhefka
- Division of Cardiology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Constantine Daskalakis
- Division of Biostatistics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Mark W. Berguson
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - John E. Bowen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - James T. Diehl
- Division of Cardiothoracic Surgery, Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Jianzhong Sun
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
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Fujikawa T, Tanaka A, Abe T, Yoshimoto Y, Tada S, Maekawa H. Effect of antiplatelet therapy on patients undergoing gastroenterological surgery: thromboembolic risks versus bleeding risks during its perioperative withdrawal. World J Surg 2015; 39:139-49. [PMID: 25201469 DOI: 10.1007/s00268-014-2760-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antiplatelet agents given to prevent thromboembolic disease are frequently withdrawn prior to surgical procedures to reduce bleeding complications. This action may expose patients to increased thromboembolic morbidity and mortality. METHODS A series of 2012 patients who had undergone gastroenterologic surgery between January 2005 and June 2010 at our institution were reviewed. Among this cohort, antiplatelet therapy (APT) was used in 519 patients (25.8 %). The perioperative management included interruption of APT 1 week before surgery and early postoperative reinstitution in patients at low thromboembolic risk, although APT was maintained until surgery in those at high thromboembolic risk. Bleeding and thromboembolic complications, as well as other outcome variables, were assessed in patients with and without APT. RESULTS Among 519 patients with APT, 99 (19.1 %) underwent multidrug APT. Among them, 124 (23.9 %) required preoperative continuation of APT. None suffered from excessive bleeding intraoperatively. There were 19 thromboembolic events (0.9 %) in the whole cohort. Postoperative bleeding complications occurred in 37 patients (1.8 %). Multivariate analysis showed that increased postoperative bleeding complications were independently associated with multidrug APT [hazard ratio (HR) 4.3, p = 0.014], high-risk surgical procedures (HR 3.5, p = 0.003), and perioperative heparin bridging (HR 2.8, p = 0.029). High-risk surgery (HR 8.3, p < 0.001) and poor performance status (HR 4.9, p = 0.005)--but neither APT nor anticoagulation use--were significant prognostic factors for thromboembolic complications. CONCLUSIONS Satisfactory outcomes were obtained during gastroenterologic surgery under rigorous perioperative management, including single-agent APT continuation in patients at high thromboembolic risk. Patients treated with multidrug APT still represent a challenging group, however, and need to be carefully managed to prevent perioperative complications.
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Affiliation(s)
- Takahisa Fujikawa
- Department of Surgery, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu, Fukuoka, 802-8555, Japan,
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