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Aboul-Hassan SS, Stankowski T, Marczak J, Peksa M, Nawotka M, Stanislawski R, Kryszkowski B, Cichon R. The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis. J Card Surg 2017; 32:758-774. [DOI: 10.1111/jocs.13250] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Tomasz Stankowski
- Department of Cardiac Surgery; Sana-Heart Center Cottbus; Cottbus Germany
| | - Jakub Marczak
- Department of Cardiac Surgery; MEDINET Heart Center Ltd.; Nowa Sol Poland
- Department of Cardiac Surgery; Wroclaw Medical University; Wroclaw Poland
| | - Maciej Peksa
- Department of Cardiac Surgery; MEDINET Heart Center Ltd.; Nowa Sol Poland
| | - Marcin Nawotka
- Department of Cardiac Surgery; MEDINET Heart Center Ltd.; Nowa Sol Poland
| | | | - Bartosz Kryszkowski
- Department of General and Oncological Surgery; Hospital in Jelenia Gora; Jelenia Gora Poland
| | - Romuald Cichon
- Department of Cardiac Surgery; Warsaw Medical University; Warsaw Poland
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Sá MPBO, Soares AF, Miranda RGA, Araújo ML, Menezes AM, Silva FPV, Lima RC. Stopping versus continuing acetylsalicylic acid before coronary artery bypass surgery: A systematic review and meta-analysis of 14 randomized controlled trials with 4499 patients. Eur J Cardiothorac Surg 2017; 52:838-847. [DOI: 10.1093/ejcts/ezx293] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/19/2017] [Indexed: 12/19/2022] Open
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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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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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Scott WW, Levy M, Rickert KL, Madden CJ, Beshay JE, Sarode R. Assessment of common nonsteroidal anti-inflammatory medications by whole blood aggregometry: a clinical evaluation for the perioperative setting. World Neurosurg 2014; 82:e633-8. [PMID: 24698769 DOI: 10.1016/j.wneu.2014.03.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/20/2013] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To help define the perioperative risk related to commonly used non-aspirin NSAIDs with whole blood platelet aggregometry. METHODS Twelve healthy volunteers were recruited. Two cyclooxygenase (COX)-1 inhibitors (ibuprofen and naproxen) and two COX-2 inhibitors (meloxicam and celecoxib) were administered, and daily whole blood platelet aggregometry studies were obtained until studies showed no platelet inhibition. Aspirin was studied at the conclusion of the study. RESULTS Ibuprofen had no inhibitory effect on platelet aggregation in all women and no inhibitory effect in 83% of men at 24 hours. All platelet function had returned to normal at 48 hours. The inhibitory effect of naproxen on platelets was absent at 48 hours in 83% of the women and 50% of men. By 72 hours all platelet studies had returned to normal. Meloxicam and celecoxib did not cause any overall inhibitory effect on platelet aggregation. CONCLUSIONS Ibuprofen and naproxen have a mild inhibitory effect on platelet aggregation compared with aspirin and this effect is undetectable by 48 hours and 72 hours, respectively. Meloxicam and celecoxib show essentially no inhibitory effect on platelet aggregation. These findings suggest that there is little bleeding risk related to platelet aggregation at 24 hours in patients who take COX-2 inhibitors and at 72 hours for those who take COX-1 inhibitor medications.
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Affiliation(s)
- William W Scott
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Michael Levy
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kim L Rickert
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christopher J Madden
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joseph E Beshay
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ravi Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Guay J, Andrew Ochroch E. Continuing Antiplatelet Therapy Before Cardiac Surgery With Cardiopulmonary Bypass: A Meta-Analysis on the Need for Reexploration and Major Outcomes. J Cardiothorac Vasc Anesth 2014; 28:90-97. [DOI: 10.1053/j.jvca.2013.03.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 11/11/2022]
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Ma X, Ma C, Yun Y, Zhang Q, Zheng X. Safety and Efficacy Outcomes of Preoperative Aspirin in Patients Undergoing Coronary Artery Bypass Grafting. J Cardiovasc Pharmacol Ther 2013; 19:97-113. [PMID: 24212980 DOI: 10.1177/1074248413509026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The administration of aspirin is traditionally discontinued prior to coronary artery bypass grafting (CABG), given a potential risk of excessive postoperative bleeding. Few studies have previously suggested the benefits of continuing aspirin until the time of surgery. The primary aim of this review is to evaluate the effects of preoperative aspirin therapy on several clinically important outcomes in patients undergoing CABG. Methods: A meta-analysis of eligible studies of patients undergoing CABG, reporting preoperative aspirin in comparison with no aspirin/placebo and our outcomes, was carried out. The safety outcomes included postoperative bleeding, packed red blood cell (PRBC) transfusion requirements, and reoperation for bleeding. The efficacy outcomes included perioperative myocardial infarction (MI), cerebrovascular accidents (CVAs), and mortality. Results: In 8 randomized controlled trials (RCTs; n = 1538), preoperative aspirin increased postoperative bleeding (difference in means = 132.30 mL; 95 % confidence interval [CI] 47.10-217.51; P = .002), PRBC transfusion requirements (difference in means = 0.67 units; 95% CI 0.10-1.24; P = .02), and reoperation for bleeding (odds ratio [OR] = 1.76; 95% CI 1.05-2.93; P = .03). In 19 observational studies (n = 19551), preoperative aspirin increased postoperative bleeding (difference in means = 132.74 mL; 95% CI 45.77-219.72; P = .003) and PRBC transfusion requirements (difference in means = 0.19 units; 95% CI 0.02-0.35; P = .02) but not reoperation for bleeding (OR = 1.13; 95% CI 0.91-1.42; P = .27). Subgroup analyses for RCTs demonstrated that aspirin given at doses ≤ 100 mg/d might not increase the postoperative bleeding, and the dose of 325 mg/d might not be a cutoff value that has clinical and statistical significance. No statistically significant differences in the rate of perioperative MI, CVAs, or mortality were seen between the 2 groups. Conclusions: Preoperative aspirin therapy is associated with increased postoperative bleeding, PRBC transfusion requirements, and reoperation for bleeding in patients undergoing CABG. Doses lower than 100 mg/d may minimize the risk of bleeding. Additional RCTs are needed to assess the effects of preoperative aspirin on the safety and efficacy outcomes in patients undergoing CABG.
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Affiliation(s)
- Xiaochun Ma
- Shandong University School of Medicine, Jinan, Shandong, China
| | - Chi Ma
- Shandong University School of Medicine, Jinan, Shandong, China
| | - Yan Yun
- Shandong University School of Medicine, Jinan, Shandong, China
| | - Qian Zhang
- Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
| | - Xia Zheng
- Shandong Provincial Hospital affiliated to Shandong University, Jinan, Shandong, China
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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9
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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10
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Alghamdi AA, Moussa F, Fremes SE. Does the Use of Preoperative Aspirin Increase the Risk of Bleeding in Patients Undergoing Coronary Artery Bypass Grafting Surgery? Systematic Review and Meta-Analysis. J Card Surg 2007; 22:247-56. [PMID: 17488432 DOI: 10.1111/j.1540-8191.2007.00402.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The traditional recommendation has been to stop Aspirin seven to 10 days prior to coronary artery bypass surgery to reduce the potential risk of bleeding. A few reports have shown that Aspirin did not increase the risk of bleeding and may be beneficial to be continued until the time of surgery. The objective of this review was to evaluate the effect of preoperative Aspirin on bleeding in patients undergoing elective bypass surgery. METHODS A meta-analysis of 10 randomized and nonrandomized studies reporting comparisons between Aspirin and control was undertaken. The primary outcome was the total amount of postoperative chest tube drainage. Secondary outcomes were the number of units of packed red blood cell transfusion, platelet transfusion, fresh frozen plasma transfusion, and number of patients reexplored for bleeding. RESULTS Ten studies, involving 1748 patients, met the inclusion criteria for this review of whom 913 were in the Aspirin group and 835 were in the control group. Pooling the results of all studies showed a significant increase in blood loss and transfusion of red blood cells and fresh frozen plasma in the Aspirin group (p < 0.05). There was no significant difference between the two groups in the rate of platelet transfusion, or the incidence of reexploration (p > 0.05). Included studies were heterogeneous and of low methodological quality. CONCLUSION Aspirin is associated with increased chest tube drainage and may be associated with a greater requirement for blood products. High-quality prospective studies are warranted to reassess the effect of Aspirin on important postoperative outcomes.
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Affiliation(s)
- Abdullah A Alghamdi
- Division of Cardiac and Vascular Surgery, Department of Surgery, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Bracey AW, Grigore AM, Nussmeier NA. Impact of platelet testing on presurgical screening and implications for cardiac and noncardiac surgical procedures. Am J Cardiol 2006; 98:25N-32N. [PMID: 17097415 DOI: 10.1016/j.amjcard.2006.09.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Bleeding is a common complication of cardiac surgery, accounting for a significant portion of the total transfusions performed in the United States. This may be due in part to surgical factors and to the fibrinolysis and platelet activation induced by cardiopulmonary bypass. The increasing frequency with which antiplatelet medications are used to prevent thrombosis in cardiac surgical patients with cardiovascular disease also elevates the risk for postoperative bleeding. The resulting coagulopathy and need for transfusions may increase morbidity and mortality risk in cardiac surgical patients, depending on the specific antiplatelet agent used, as well as on patient factors. Empiric platelet transfusion, the frequency of which varies greatly among institutions, does not reliably prevent these complications and may even increase the risk for adverse outcomes. Platelet function testing, particularly with newer testing systems, may be a valuable tool for making decisions about stopping antiplatelet drug administration, surgical timing with respect to bleeding risk, and platelet transfusion in cardiac surgical patients.
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Affiliation(s)
- Arthur W Bracey
- Division of Cardiovascular Pathology, The Texas Heart Institute at St. Luke's Episcopal Hospital and Baylor College of Medicine, Houston, Texas 77225, USA.
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Sun JCJ, Crowther MA, Warkentin TE, Lamy A, Teoh KHT. Should Aspirin Be Discontinued Before Coronary Artery Bypass Surgery? Circulation 2005; 112:e85-90. [PMID: 16103244 DOI: 10.1161/circulationaha.105.546697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jack C J Sun
- Division of Cardiac Surgery, McMaster University, Hamilton, Canada.
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Ferraris VA, Ferraris SP, Moliterno DJ, Camp P, Walenga JM, Messmore HL, Jeske WP, Edwards FH, Royston D, Shahian DM, Peterson E, Bridges CR, Despotis G. The Society of Thoracic Surgeons Practice Guideline Series: Aspirin and Other Antiplatelet Agents During Operative Coronary Revascularization (Executive Summary)*. Ann Thorac Surg 2005; 79:1454-61. [PMID: 15797109 DOI: 10.1016/j.athoracsur.2005.01.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Victor A Ferraris
- University of Kentucky Chandler Medical Center, Lexington, Kentucky 40536, USA.
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Ojanen R, Kaukinen L, Seppälä E, Kaukinen S, Vapaatalo H. Single dose of acetylsalicylic acid prevents thromboxane release after tourniquet ischemia. THE JOURNAL OF TRAUMA 2003; 54:986-9. [PMID: 12777914 DOI: 10.1097/01.ta.0000051589.20214.5a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ischemia, such as that caused by a tourniquet, stimulates thromboxane (Tx) A(2) synthesis. TxA(2) might sensitize the operated limb to various complications, such as compartment syndrome and thromboembolic events. METHODS We studied the effect of pretreatment with a single dose of acetylsalicylic acid (ASA) (25, 100, and 500 mg) given 3 hours before surgery on the formation of TxB(2), a stable metabolite of TxA(2), after tourniquet deflation in 32 knee or ankle surgery patients. RESULTS Tourniquet time varied between 60 +/- 8 to 71 +/- 7 (SE) minutes. In control patients without ASA pretreatment, the platelet-produced femoral vein serum TxB(2) concentration over 30 minutes in vitro coagulation increased remarkably (from 40.0 +/- 20 ng/mL to 73.5 +/- 39 ng/mL) immediately after tourniquet deflation. Plasma concentrations increased similarly, approximately threefold. Pretreatment with 100 or 500 mg ASA prevented the increase in TxB(2) concentrations. Radial artery concentrations of TxB(2) were similar to venous concentrations in the different treatment groups. CONCLUSION Pretreatment with a single 100-mg dose of ASA prevents the release of TxB(2) after tourniquet deflation.
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Affiliation(s)
- Raimo Ojanen
- Department of Anaesthesia and Intensive Care, Tampere University Hospital, Finland
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Ferraris VA, Ferraris SP, Joseph O, Wehner P, Mentzer RM. Aspirin and postoperative bleeding after coronary artery bypass grafting. Ann Surg 2002; 235:820-7. [PMID: 12035038 PMCID: PMC1422511 DOI: 10.1097/00000658-200206000-00009] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the relationship between aspirin ingestion and postoperative bleeding complications, and to test the hypothesis that there is a subset of patients who are aspirin hyperresponders with a proclivity toward platelet dysfunction. SUMMARY BACKGROUND DATA Despite numerous retrospective and prospective analyses, it is still controversial as to whether aspirin ingestion before coronary artery bypass grafting (CABG) is associated with significant postoperative bleeding. METHODS Between January 1995 and December 1999, the records of 2,606 consecutive patients undergoing CABG were reviewed to identify patients with a history of aspirin ingestion up until the time of surgery. Aspirin ingestion was correlated with postoperative blood transfusion using multivariate analysis. In a subset of preoperative aspirin users (n = 40), bleeding times were measured before and after aspirin use. Flow cytometry was performed in another cohort of patients with known heart disease (n = 30) to determine the effect of aspirin on platelet surface receptors. RESULTS During the 5-year study period, 63% of the CABG patients were identified as aspirin users. Among these, 23.1% required blood transfusions compared with 19% for the nonusers. Non-red blood cell transfusions were more common in aspirin users, as was reexploration for bleeding. Stratification of these results according to the frequency of aspirin use showed that aspirin is an independent multivariate predictor of postoperative blood transfusion only in high-risk patients. In the prospective studies, aspirin treatment resulted in a significant increase in the template bleeding time, an increase in platelet PAR-1 thrombin receptor activity, and a decrease in the binding of platelets to monocytes. CONCLUSIONS The findings support the hypothesis that aspirin is associated with a greater likelihood of postoperative bleeding. A platelet function testing algorithm that combines preoperative risk factor assessment, template bleeding times, and flow cytometry may allow the identification of aspirin hyperresponders who are at increased risk for bleeding.
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Affiliation(s)
- Victor A Ferraris
- Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington 40536-0084, USA.
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Abstract
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can produce a mild, systemic hemostatic defect by inhibiting normal platelet function. Aspirin acetylates and permanently inactivates cyclooxygenase (COX), while nonaspirin NSAIDs reversibly block COX; thus, all of these drugs cause platelet dysfunction by inhibiting the formation of thromboxane A2, a platelet-activating and vasoconstricting eicosanoid. However, spontaneous bleeding complications outside the gastrointestinal tract very rarely result from the use of aspirin and other NSAIDs in individuals who are otherwise hemostatically normal. Most types of surgery are not usually associated with clinically significant bleeding in patients taking these drugs, making it typically unnecessary to discontinue them and thus delay surgery for the purpose of restoring normal hemostasis. Exceptions may include operations at sites where optimal hemostasis is critical, surgical manipulation of the genitourinary tract and oral cavity, and possibly cardiac surgery. Factors that increase the risk of bleeding with aspirin and other NSAIDs include coexisting coagulation abnormalities and the simultaneous use of alcohol or anticoagulants.
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Affiliation(s)
- A I Schafer
- Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
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Klein M, Keith PR, Dauben HP, Schulte HD, Beckmann H, Mayer G, Elert O, Gams E. Aprotinin counterbalances an increased risk of peri-operative hemorrhage in CABG patients pre-treated with Aspirin. Eur J Cardiothorac Surg 1998; 14:360-6. [PMID: 9845139 DOI: 10.1016/s1010-7940(98)00192-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE As Aspirin (ASA) has proven efficacy in preventing patients with CAD from complications related to cardiovascular diseases, most patients scheduled for CABG are treated with ASA therapy. Consequently, impaired hemostasis is a problem in the management of CABG patients. Clinical studies have shown that Aprotinin can reduce bleeding and the use of blood products by 50% in patients both with and without pre-operative ASA therapy. Concerning the combined effect of peri-operative low-dose ASA therapy and intra-operative high-dose Aprotinin therapy, the gathering of additional and prospective data seemed to be necessary. METHODS We conducted a double-blind two-centre randomised three-arm study in patients with elective primary CABG surgery. Three groups have been tested, comprising 119 patients in total (group A: ASA + Aprotinin, group B: placebo + Aprotinin, group C: placebo + placebo) to investigate a possible reduction of bleeding in Aprotinin treated patients. For all patients, thromboxane levels were used to identify ASA or placebo treatment. RESULTS The post-operative blood loss is significantly reduced by 21% after Trasylol administration (B vs. C; P = 0.009). The unexpected result of this study has been that the pre-treatment with ASA led to a further reduction of 18% (A vs. C; P < 0.0001). The difference between the two Aprotinin groups (A and B) is significant (P = 0. 01) in favour of ASA pre-treatment. Myocardial infarction (MI) had been diagnosed at levels of 1.8% in total (2/113), 2.6% (1/38) in group B and 3.2% (1/31 ) in group C. An additional blinded evaluation of ECG, enzyme levels and clinical status revealed 'definite, probable and possible' MIs of 5% in group A, compared to 16% in group B and 13% in group C, thus providing no evidence for a higher risk of infarction by Aprotinin treatment. When comparing the ASA group to non-ASA pre-treatment, a strong trend towards a reduction in MI rate becomes obvious, from 15% to 5% in favour of the ASA pre-treatment (P = 0.08). Concerning other peri-operative complications, no statistical difference between the groups could be detected. CONCLUSIONS A reduction in post-operative blood loss in primary elective CABG surgery with intra-operative Aprotinin treatment could be confirmed. A low-dose ASA treatment combined with a high-dose aprotinin administration during surgery not only neutralized a potentially higher risk of bleeding, but did in fact reduce the post-operative blood loss. The protective effect of ASA on peri-operative MI has been evident through a reduction of MI rate in ASA treated patients.
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Affiliation(s)
- M Klein
- Heinrich-Heine-University Duesseldorf, Department of Thoracic- and Cardiovascular Surgery, Germany.
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Schafer AI. Effects of nonsteroidal antiinflammatory drugs on platelet function and systemic hemostasis. J Clin Pharmacol 1995; 35:209-19. [PMID: 7608308 DOI: 10.1002/j.1552-4604.1995.tb04050.x] [Citation(s) in RCA: 224] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Aspirin and nonaspirin nonsteroidal antiinflammatory drugs (NSAIDs) inhibit platelet cyclooxygenase, thereby blocking the formation of thromboxane A2. These drugs produce a systemic bleeding tendency by impairing thromboxane-dependent platelet aggregation and consequently prolonging the bleeding time. Aspirin exerts these effects by irreversibly blocking cyclooxygenase and, therefore, its actions persist for the circulating lifetime of the platelet. Nonaspirin NSAIDs inhibit cyclooxygenase reversibly and, therefore, the duration of their action depends on specific drug dose, serum level, and half-life. The clinical risks of bleeding with aspirin or nonaspirin NSAIDs are enhanced by the concomitant use of alcohol or anticoagulants and by associated conditions, including advanced age, liver disease, and other coexisting coagulopathies.
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Affiliation(s)
- A I Schafer
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Freed MI, Audet PR, Zariffa N, Krishna GG, Ilson BE, Everitt DE, Brown LE, Rizzo SM, Nichols AI, Jorkasky DK. Comparative effects of nabumetone, sulindac, and indomethacin on urinary prostaglandin excretion and platelet function in volunteers. J Clin Pharmacol 1994; 34:1098-108. [PMID: 7876402 DOI: 10.1002/j.1552-4604.1994.tb01987.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Nonsteroidal antiinflammatory drugs differ with respect to their effects on prostaglandin metabolism in various tissues, a property that may be partly responsible for some of the differences in the pharmacologic activities and side-effect profiles that are associated with their use. The effects of nabumetone on urinary prostaglandin excretion have not been reported. Fourteen healthy females, age 21-43 years, were treated with nabumetone (NAB) 1000 mg daily, sulindac (SUL) 200 mg every 12 hours, and indomethacin (IND) 50 mg every 12 hours for 7 days in a randomized period-balanced crossover study. The effects of drug treatment on urinary prostaglandin excretion (PGE2, 6-keto-PGF1 alpha, PGF2 alpha, thromboxane [TX] B2) and platelet function (collagen-induced whole blood platelet aggregation [CIPA] and template bleeding time) were determined on day 1 and day 7. For each treatment regimen, mean baseline urinary PG excretion values were comparable for each prostanoid, but the pattern of excretion differed in response to each drug. Treatment with NAB significantly increased the urinary excretion rates of PGE2 and PGF2 alpha, but 6-keto-PGF1 alpha and TXB2 excretion were unchanged. IND treatment did not result in a significant change in PGE2 excretion but did significantly reduce urinary 6-keto-PGF1 alpha and TXB2 excretion rates. Reduced excretion of PGF2 alpha was observed on both study days during treatment with IND and SUL. SUL treatment also resulted in increased urinary PGE2 excretion while significantly reducing 6-keto-PGF1 alpha excretion on day 7. Significant differences were observed between the NAB and SUL regimens with respect to PGF2 alpha excretion and between the NAB and SUL regimens for PGE2, PGF2 alpha, 6-keto-PGF alpha 1 (on day 1 only) and TXB2 (on day 1 only). Neither NAB nor SUL caused inhibition of CIPA or bleeding time although platelet aggregation was inhibited during IND treatment. That NAB treatment was neither associated with alterations in platelet function nor decreases in the urinary excretion of the vasodilatory prostaglandins, PGE2 and 6-keto-PGF1 alpha, suggests that NAB possesses renal sparing properties.
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Affiliation(s)
- M I Freed
- Clinical Research Unit, SmithKline Beecham, Presbyterian Medical Center of Philadelphia, PA 19104
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Schönberger JP, Bredée JJ, van Oeveren W, van Zundert AA, Verkroost M, Terwoorst J, Bavinck JH, Berreklouw E, Wildevuur CR. Preoperative therapy of low-dose aspirin in internal mammary artery bypass operations with and without low-dose aprotinin. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)34124-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- J N George
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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Taggart DP, Siddiqui A, Wheatley DJ. Low-dose preoperative aspirin therapy, postoperative blood loss, and transfusion requirements. Ann Thorac Surg 1990; 50:424-8. [PMID: 2400264 DOI: 10.1016/0003-4975(90)90488-r] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The effects of three low-dose regimens of preoperative aspirin therapy on postoperative blood loss, transfusion requirements, and length of hospital stay were recorded in a prospective cohort study of 202 patients undergoing elective coronary artery bypass grafting. One hundred one patients had been prescribed daily aspirin by the referring cardiologist (44 at 75 mg, 28 at 150 mg, and 29 at 300 mg); the remaining 101 patients who had not been prescribed aspirin acted as a control group. A median postoperative blood loss of 870 mL in the control group was increased by 280 mL in the 75-mg aspirin group (p less than 0.001), by 490 mL in the 150-mg aspirin group (p less than 0.001), and by 230 mL in the 300-mg aspirin group (p = 0.03). The median requirement for blood transfusion of 2 U red blood cell concentrates in the control group was increased by 2 U in the 75-mg aspirin group (p less than 0.001), 2 U in the 150-mg aspirin group (p less than 0.001), and 1 U in the 300-mg aspirin group (p = 0.05). Hemostatic "packs" (fresh frozen plasma, platelets, and cryoprecipitate) were required in 20 patients in the aspirin groups as compared with 5 in the control group (p less than 0.01 by chi 2 test). The mean postoperative hospital stay was 8 days for all groups. Regular daily low-dose aspirin therapy produces significant increases in postoperative blood loss, resulting in a substantial increase in blood transfusion and hemostatic pack requirements, but does not prolong postoperative hospital stay.
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Affiliation(s)
- D P Taggart
- Department of Cardiac Surgery, Royal Infirmary, Glasgow, Scotland
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Sethi GK, Copeland JG, Goldman S, Moritz T, Zadina K, Henderson WG. Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. Department of Veterans Affairs Cooperative Study on Antiplatelet Therapy. J Am Coll Cardiol 1990; 15:15-20. [PMID: 2404046 DOI: 10.1016/0735-1097(90)90168-o] [Citation(s) in RCA: 177] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The perioperative consequences of preoperative aspirin administration were assessed in a large prospective cooperative study of 772 patients undergoing coronary artery bypass grafting. The 772 patients were randomized to receive either aspirin (325 mg once a day), aspirin (325 mg three times a day), aspirin plus dipyridamole (325 and 75 mg together three times a day) (aspirin group), sulfinpyrazone (267 mg three times a day) or placebo (nonaspirin group). The therapy, except in the aspirin group, was started 48 h before the operation. In all aspirin subgroups, one 325 mg aspirin dose was given 12 h before surgery and maintained thereafter according to the assigned regimen. Patients in the aspirin group had significantly more postoperative bleeding and received more packed blood cells and blood products than did patients in the nonaspirin group. Although total operative duration and cardiopulmonary bypass duration were not different, the interval between completion of cardiopulmonary bypass and wound closure was significantly longer (p = 0.035) in the aspirin group. Thirty-one (6.6%) of 471 patients in the aspirin group and 5 (1.7%) of 301 patients in the nonaspirin group also required reoperation for control of postoperative bleeding (p = 0.002). The site of bleeding found at reoperation was not different between the two groups. There was no difference in operative mortality rates, incidence of other bleeding complications or occurrence of other post-operative complications between the two groups. Thus, antiplatelet regimens involving preoperative initiation of aspirin therapy, which has been shown to improve graft patency, increase the risk of abnormal postoperative bleeding and the need for reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G K Sethi
- Division of Cardiothoracic Surgery, Department of Veterans Affairs Medical Center, Tucson, Arizona 85723
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Giordano GF, Giordano GF, Rivers SL, Chung GK, Mammana RB, Marco JD, Raczkowski AR, Sabbagh A, Sanderson RG, Strug BS. Determinants of homologous blood usage utilizing autologous platelet-rich plasma in cardiac operations. Ann Thorac Surg 1989; 47:897-902. [PMID: 2502951 DOI: 10.1016/0003-4975(89)90031-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The present study evaluated (1) the influence of the collection of autologous platelet-rich plasma intraoperatively in addition to intraoperative autotransfusion on homologous blood usage and bleeding in cardiac operations; (2) the influence of age, sex, body surface area, type of operation, and reoperations on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively; and (3) the influence of the preoperative administration of aspirin, Persantine (dipyridamole), heparin sodium, thrombolytic agents, Coumadin (crystalline warfarin sodium), and nonsteroid, antiinflammatory drugs on homologous blood usage and bleeding in cardiac operations utilizing intraoperative autotransfusion and autologous platelet-rich plasma collected intraoperatively. The results demonstrated a decrease in homologous blood use and bleeding when autologous platelet-rich plasma is collected in addition to the use of intraoperative autotransfusion. All of the patient and procedural variables influenced homologous blood usage and bleeding to some extent. Only the thrombolytic agents affected blood usage by increasing homologous plasma usage. All other drugs evaluated did not influence blood utilization or the amount of bleeding intraoperatively or postoperatively.
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Affiliation(s)
- G F Giordano
- Southern Arizona Regional Red Cross Blood Program, Tucson 85719
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Ferraris VA, Ferraris SP, Lough FC, Berry WR. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Ann Thorac Surg 1988; 45:71-4. [PMID: 3257376 DOI: 10.1016/s0003-4975(10)62401-0] [Citation(s) in RCA: 148] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Thirty-four patients were entered into a non-blinded, randomized study to test the effect of preoperative aspirin ingestion on postoperative blood loss and transfusion requirements after coronary artery bypass grafting. Sixteen patients in the aspirin-treated group had significantly increased chest-tube blood loss 12 hours after operation (1,513 +/- 978 versus 916 +/- 482 ml; p = 0.038). In addition, aspirin users had significantly increased requirements for postoperative packed red blood cells (4.4 +/- 3.5 versus 1.8 +/- 1.3 units; p = 0.014), platelets (1.3 +/- 1.3 versus 0.2 +/- 0.4 six-donor units, p = 0.0049), and fresh-frozen plasma (3.6 +/- 5.0 versus 0.78 +/- 1.6 units; p = 0.042) transfusions. The only patients requiring reoperation for bleeding were in the aspirin-treated group (2 patients). Six patients were not entered into the randomized part of the study because of excessively prolonged post-aspirin bleeding times (greater than 10 minutes). This finding suggests that a subset of patients are particularly sensitive to aspirin and have significantly prolonged bleeding times after aspirin ingestion. We conclude that aspirin ingestion increases postoperative blood loss and transfusion requirements, and we recommend discontinuation of aspirin therapy before cardiac procedures.
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Affiliation(s)
- V A Ferraris
- Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, CA 94129-6700
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