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Dai M, Furuya-Kanamori L, Syed A, Lin L, Wang Q. An empirical comparison of the harmful effects for randomized controlled trials and non-randomized studies of interventions. Front Pharmacol 2023; 14:1064567. [PMID: 37025494 PMCID: PMC10070801 DOI: 10.3389/fphar.2023.1064567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Introduction: Randomized controlled trials (RCTs) are the gold standard to evaluate the efficacy of interventions (e.g., drugs and vaccines), yet the sample size of RCTs is often limited for safety assessment. Non-randomized studies of interventions (NRSIs) had been proposed as an important alternative source for safety assessment. In this study, we aimed to investigate whether there is any difference between RCTs and NRSIs in the evaluation of adverse events. Methods: We used the dataset of systematic reviews with at least one meta-analysis including both RCTs and NRSIs and collected the 2 × 2 table information (i.e., numbers of cases and sample sizes in intervention and control groups) of each study in the meta-analysis. We matched RCTs and NRSIs by their sample sizes (ratio: 0.85/1 to 1/0.85) within a meta-analysis. We estimated the ratio of the odds ratios (RORs) of an NRSI against an RCT in each pair and used the inverse variance as the weight to combine the natural logarithm of ROR (lnROR). Results: We included systematic reviews with 178 meta analyses, from which we confirmed 119 pairs of RCTs and NRSIs. The pooled ROR of NRSIs compared to that of RCTs was estimated to be 0.96 (95% confidence interval: 0.87 and 1.07). Similar results were obtained with different sample size subgroups and treatment subgroups. With the increase in sample size, the difference in ROR between RCTs and NRSIs decreased, although not significantly. Discussion: There was no substantial difference in the effects between RCTs and NRSIs in safety assessment when they have similar sample sizes. Evidence from NRSIs might be considered a supplement to RCTs for safety assessment.
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Affiliation(s)
- Minhan Dai
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, China
| | - Luis Furuya-Kanamori
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, QL, Australia
| | - Asma Syed
- Department of Population Medicine, College of Medicine, Qatar University, Doha, Qatar
| | - Lifeng Lin
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, AZ, United States
| | - Qiang Wang
- Mental Health Center, West China Hospital of Sichuan University, Chengdu, China
- *Correspondence: Qiang Wang,
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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3
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Singh V, Kapoor S, Singh G, Arya R, Garg A, Ralhan S, Gupta V, Mohan B, Wander G, Gupta R. Effect of anti-platelet therapy on peri-operative blood loss in patients undergoing off-pump coronary artery bypass grafting. Ann Card Anaesth 2022; 25:182-187. [PMID: 35417965 PMCID: PMC9244270 DOI: 10.4103/aca.aca_12_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Purpose: The purpose of this study was to review the effect of the pre-operative use of clopidogrel and aspirin on peri-operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG). Materials and Methods: A total of 1200 patients who underwent off-pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on-pump CABG, and the combined procedure were excluded from the study. Results: Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post-operatively, this was statistically significant. Re-exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients. Conclusion: The pre-operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.
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4
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Rogers AL, Allman RD, Fang X, Kindell LC, Nifong LW, Degner BC, Akhter SA. Thromboelastography-Platelet Mapping Allows Safe and Earlier Urgent Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 113:1119-1125. [PMID: 34437860 DOI: 10.1016/j.athoracsur.2021.07.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/01/2021] [Accepted: 07/19/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current STS guidelines recommend delaying CABG for several days or performing platelet function testing in stable patients who received P2Y12 inhibitors. Our program routinely uses thromboelastography-platelet mapping (TEG-PM) to expedite CABG in P2Y12 non-responders (NR). We hypothesize that P2Y12 NR had no difference in LOS to surgery and blood product transfusion compared to patients undergoing urgent inpatient CABG not treated with a P2Y12 inhibitor. METHODS A total of 221 patients from 2015-2019 were P2Y12 NR based on TEG-PM result of < 50% ADP inhibition. The control group was 232 consecutive patients who also had urgent inpatient CABG but were not treated pre-operatively with a P2Y12 inhibitor. Exclusion criteria were identical between groups. RESULTS Sixty-seven percent of inpatient CABG patients who were treated pre-operatively with a P2Y12 inhibitor were NR. The mean number of days from cardiac surgical consultation to CABG in the TEG-PM NR group was 1.6 ± 0.1 versus 2.1 ± 0.1 in the control group (p<0.01). The mean total number of blood product units transfused was 1.6 ± 0.2 in the TEG-PM NR group versus 1.6 ± 0.4 in controls (p=0.91). CONCLUSIONS Our results demonstrate a very high incidence of P2Y12 non-responders in patients undergoing urgent CABG at our program. These patients underwent surgery at least 3 days earlier than STS recommendations and common practice with no difference in transfusion requirement. Routine use of TEG-PM to identify P2Y12 NR can safely decrease pre-operative hospital LOS and associated cost and improve resource utilization and patient satisfaction.
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Affiliation(s)
- Austin L Rogers
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Robert D Allman
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Xiangming Fang
- Department of Biostatistics, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina
| | - Linda C Kindell
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Leslie W Nifong
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Benjamin C Degner
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Shahab A Akhter
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
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5
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Comentale G, Palma G, Parisi V, Simeone S, Pucciarelli G, Manzo R, Pilato E, Giordano R. Preoperative Aspirin Management in Redo Tetralogy of Fallot Population: Single Centre Experience. Healthcare (Basel) 2020; 8:healthcare8040455. [PMID: 33153007 PMCID: PMC7712109 DOI: 10.3390/healthcare8040455] [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] [Received: 10/09/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose: Redo operations and preoperative antiplatelet/anticoagulant therapy can significantly increase surgical risk in congenital heart surgery. This is a retrospective study on the impact of preoperative aspirin therapy on the outcome of Tetralogy of Redo Fallot patients undergoing right ventricle outflow tract (RVOT) conduit implantation. Methods: Ten-years retrospective analysis of medical records was carried out. A total of 72 patients were divided into two groups: “Daily-on-ASA” group on daily therapy with aspirin (ASA) until 5 days from surgery and “No-Home-ASA” without it. Propensity match analysis was done in order to standardize the populations. Intraoperative and postoperative lengths were compared as well as the need for inotropic support. In addition, differences in blood transfusions and need for Fresh frozen plasma (FFP)/platelets (PLT) were analysed. Findings: Intraoperative lengths were similar between the groups. Not statistically significative differences about postoperative time to extubation (p = 0.34), ICU Stay (p = 0.31) or in-hospital stay (p = 0.36) were found. Drain loss was higher in the “Daily-on-ASA” group (407.9 ± 96.7 mL vs. 349.5 ± 84.3 mL; p = 0.03) as well as blood transfusions (372.7 ± 255.1 mL vs. 220.1 ± 130.3 mL, p = 0.02) and PLT/FFP need (217.7 ± 132.1 mL vs. 118.7 ± 147.1 mL, p = 0.01). No differences were found in postoperative complications or re-explorations for bleeding. Implications: We found no advantages in surgical times and hospital stay comparing redo patients who stopped aspirin versus those that didn’t take it in the last 6 months. However, our results suggest that redo patients undergoing RVOT conduit implantation who take daily aspirin are at higher risk of bleeding even if it is stopped 5 days before surgery.
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Affiliation(s)
- Giuseppe Comentale
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Gaetano Palma
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Valentina Parisi
- Department of Translational Medical Sciences-University of Naples Federico II, 80131 Naples, Italy;
| | - Silvio Simeone
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (S.S.); (G.P.)
| | - Gianluca Pucciarelli
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy; (S.S.); (G.P.)
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Emanuele Pilato
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
| | - Raffaele Giordano
- Department of Advanced Biomedical Sciences, Adult and Pediatric Cardiac Surgery-University of Naples Federico II, 80131 Naples, Italy; (G.C.); (G.P.); (R.M.); (E.P.)
- Correspondence:
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6
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Agarwal S, Abdelmotieleb M. Viscoelastic testing in cardiac surgery. Transfusion 2020; 60 Suppl 6:S52-S60. [PMID: 32955756 DOI: 10.1111/trf.16075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti-platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri-operative testing to reduce transfusion.
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Affiliation(s)
- Seema Agarwal
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| | - Mohamed Abdelmotieleb
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
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7
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Marteinsson SA, Heimisdóttir AA, Axelsson TA, Johannesdottir H, Arnadottir LO, Gardarsdottir HR, Johnsen A, Sigurdsson MI, Helgadottir S, Gudbjartsson T. Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes. SCAND CARDIOVASC J 2020; 54:265-273. [PMID: 32351135 DOI: 10.1080/14017431.2020.1751265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.
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Affiliation(s)
| | | | - Tomas A Axelsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Hera Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Linda O Arnadottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga R Gardarsdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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8
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Cheng Y, Liu X, Zhao Y, Sun Y, Zhang D, Liu F, Ma Y, Zhou Y. Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery. Angiology 2020; 71:704-712. [PMID: 32295386 DOI: 10.1177/0003319720919319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This retrospective study assessed the risk factors for adverse events following off-pump coronary artery bypass graft (CABG) surgery with dual antiplatelet therapy (DAPT). Records (between 2013 and 2017) were reviewed for patients who discontinued DAPT (clopidogrel 75 mg and aspirin 100 mg) ≤5 days before off-pump CABG. The primary outcome was the incidence of a Bleeding Academic Research Consortium (BARC) type 4 major event. Factors associated with bleeding events and perioperative myocardial ischemia were evaluated using multivariable logistic regression. The incidence of major bleeding events was 17.6% in 2012 patients. Adjusted multiple logistic regression analysis showed that the risk of postoperative bleeding increased when DAPT was discontinued <3 days before surgery (day 2: adjusted odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.09-2.64; day 1: adjusted OR: 2.37, 95% CI: 1.49-3.77; day 0: adjusted OR: 2.45, 95% CI: 1.53-3.92). The adjusted risk of mortality (OR: 13.14, 95% CI: 4.55-37.94) was increased with bleeding complications. In subgroup analysis, perioperative myocardial ischemia was related to increased blood loss (adjusted OR: 1.10, 95% CI: 1.02-1.18). Aspirin and clopidogrel should optimally be discontinued >3 days before CABG to reduce the risk of bleeding complications, myocardial ischemia, and death.
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Affiliation(s)
- Yujing Cheng
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Xiaoli Liu
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yingxin Zhao
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yan Sun
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Dai Zhang
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Fang Liu
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yue Ma
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
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9
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Platelet Activity Measured by VerifyNow® Aspirin Sensitivity Test Identifies Coronary Artery Bypass Surgery Patients at Increased Risk for Postoperative Bleeding and Transfusion. Heart Lung Circ 2020; 29:460-468. [DOI: 10.1016/j.hlc.2019.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 03/01/2019] [Accepted: 03/19/2019] [Indexed: 11/19/2022]
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10
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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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11
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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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12
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Bingham BA, Huang SY, Chien PL, Ensor JE, Gupta S. Pulmonary Hemorrhage Following Percutaneous Computed Tomography-Guided Lung Biopsy: Retrospective Review of Risk Factors, Including Aspirin Usage. Curr Probl Diagn Radiol 2018; 49:12-16. [PMID: 30470549 DOI: 10.1067/j.cpradiol.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND To evaluate the significance of aspirin, as well as, other potential confounding risk factors, on the incidence and volume of pulmonary hemorrhage in patients undergoing percutaneous computed tomography-guided lung biopsy. METHODS This retrospective study was approved by the institutional review board. Between September 2013 and December 2014, 252 patients taking aspirin underwent transthoracic computed tomography-guided lung biopsy. Patient, technical, and lesion-related risk factors were evaluated. Univariate analysis was performed with a Student's t test, chi-square test, or Fisher's exact test, as appropriate followed by multivariate logistic regression. RESULTS Of 252 patients, 49 (19.4%) continued or stopped aspirin ≤4 days prior to biopsy and 203 (80.6%) patients stopped aspirin ≥5 days prior to biopsy. Pulmonary hemorrhage occurred in 174 cases (69.0%). The median volume of hemorrhage was 3.74 cm3 (range, 0-163.5 cm3). Multivariate analysis revealed that lesion size (P < 0.0001) and lesion depth (P < 0.0001) were independent risk factors for the incidence of pulmonary hemorrhage, while lesion size (P = 0.0035), transgression of intraparenchymal vessels (P < 0.0001), and lesion depth (P = 0.0047) were independent risk factors for severity of hemorrhage. Aspirin stopped ≤4 days from a percutaneous lung biopsy was not associated with pulmonary hemorrhage. CONCLUSION Aspirin taken concurrently or stopped within 4 days of transthoracic lung biopsy is not an independent risk factor for pulmonary hemorrhage. The incidence of hemorrhage following lung biopsy is associated with lesion size and depth, while the severity of hemorrhage is associated with lesion size, depth, as well as traversal of intraparenchymal vessels.
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Affiliation(s)
- Brigid A Bingham
- The University of Texas MD Anderson Cancer Center, Department of Interventional Radiology, Houston, TX
| | - Steven Y Huang
- The University of Texas MD Anderson Cancer Center, Department of Interventional Radiology, Houston, TX.
| | - Pamela L Chien
- The University of Texas MD Anderson Cancer Center, Department of Interventional Radiology, Houston, TX
| | - Joe E Ensor
- Houston Methodist Research Institute, Houston Methodist Cancer Center, Houston, TX
| | - Sanjay Gupta
- The University of Texas MD Anderson Cancer Center, Department of Interventional Radiology, Houston, TX
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13
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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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14
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Vlot EA, Willemsen LM, Van Dongen EPA, Janssen PW, Hackeng CM, Kloppenburg GTL, Kelder JC, Ten Berg JM, Noordzij PG. Perioperative point of care platelet function testing and postoperative blood loss in high-risk cardiac surgery patients. Platelets 2018; 30:982-988. [PMID: 30411659 DOI: 10.1080/09537104.2018.1542123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Postoperative coagulopathic bleeding is common in cardiac surgery and associated with increased morbidity and mortality. Platelet function is affected by multiple factors, including patient and procedural characteristics. Point-of-care (POC) multiple electrode aggregometry (MEA) can rapidly detect and quantify platelet dysfunction and could contribute to optimal patient blood management. In patients undergoing CABG and heart valve surgery platelet function was assessed using POC MEA at four different perioperative timepoints in response to stimulation with four specific receptor agonists (ADP, AA, COL, TRAP). Postoperative bleeding was recorded during 24 h after surgery. Regression analyses were performed to establish associations between perioperative platelet function and postoperative blood loss. Ninety-nine patients were included in the study. Fifty-nine patients (60%) were on antiplatelet therapy (APT) at time of surgery. ADP- and AA-induced platelet aggregation declined during CPB and after decannulation from CPB, with a maximum decrease of 55% for ADP (35 vs. 77 AU at baseline; P < 0.001) and 78% for ASPI (14 vs. 64 AU at baseline; P < 0.001). A linear relationship was present between ADP-induced platelet aggregometry at baseline and postoperative blood loss (r = -0.249; P = 0.015). In aspirin users, the maximum decline in platelet function between baseline and CPB decannulation was related to postoperative blood loss (r = 0.308; P = 0.037). In multivariate analysis, a reduced ADP platelet function prior to surgery remained associated with postoperative blood loss (r = -0.239; P = 0.012). Reduced ADP-induced platelet aggregation at baseline is associated with increased postoperative blood loss in high-risk cardiac surgery patients.
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Affiliation(s)
- Eline A Vlot
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Eric P A Van Dongen
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Paul W Janssen
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Christian M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital , Nieuwegein , The Netherlands
| | | | - Johannes C Kelder
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Peter G Noordzij
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
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15
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Metabolism of liver CYP450 and ultrastructural changes after long-term administration of aspirin and ibuprofen. Biomed Pharmacother 2018; 108:208-215. [PMID: 30219678 DOI: 10.1016/j.biopha.2018.08.162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/20/2018] [Accepted: 08/31/2018] [Indexed: 12/18/2022] Open
Abstract
Worldwide, aspirin and ibuprofen are the most commonly used non-steroidal anti-inflammatory drugs (NSAIDs). Some adverse reactions, including gastrointestinal reactions, have been concerned extensively. Nevertheless, the mechanism of liver injury remains unclear. In the present study, we focused on the metabolism of liver cytochrome P450 (CYP450) and ultrastructural morphology of liver cells. A total of thirty rats were divided into three groups of 10. Rats in the aspirin and ibuprofen groups were given enteric-coated aspirin (15 mg/kg) and ibuprofen (15 mg/kg), respectively by gavage for four weeks. The body weights were recorded every two days. Liver function and metabolic capacity of CYP450 were studied on days 14 and 28. We then conducted ultrastructural examinations. Body weights in the Ibuprofen group were lower than those of the Control group, and ALT and AST levels were significantly higher (P < 0.05). There were no significant differences in terms of body weight, ALT or AST between the Aspirin and Control groups. The metabolic capacity of CYP450 was evaluated using five probe drugs, phenacetin, tolbutamide, metoprolol, midazolam, and bupropion. We found that ibuprofen and aspirin induced metabolism of the probe drugs. Moreover, according to the pharmacokinetic data, the Control, Aspirin and Ibuprofen groups could be discriminated accurately. Ultrastructural examination showed that the number of mitochondria was increased in both the Ibuprofen and Aspirin groups. Long-term administration of enteric-coated aspirin and ibuprofen induced the metabolic activity of the CYP450 enzyme. Aspirin had better tolerability than did ibuprofen, as reflected by pharmacokinetic data of probe drug metabolism.
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16
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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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17
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Use of aspirin and bleeding-related complications after hepatic resection. Br J Surg 2018; 105:429-438. [DOI: 10.1002/bjs.10697] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/08/2017] [Accepted: 08/22/2017] [Indexed: 12/22/2022]
Abstract
Abstract
Background
The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort.
Methods
Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo–Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality.
Results
Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09).
Conclusion
This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.
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18
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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19
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Grove EL, Hossain R, Storey RF. Platelet function testing and prediction of procedural bleeding risk. Thromb Haemost 2017; 109:817-24. [DOI: 10.1160/th12-11-0806] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 02/16/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe essential role of platelets in haemostasis underlies the relationship between platelet function and spontaneous or procedure-related bleeding, which has important prognostic implications. Although not routinely undertaken, platelet function testing offers the potential to tailor antiplatelet therapy for individual patients. However, uncertainties remain about how well platelet function testing may predict haemostasis and guide management of bleeding risk. Studies of aspirin, P2Y12 inhibitors and other antiplatelet drugs clearly demonstrate how inhibition of platelet function increases bleeding risk. More potent antiplatelet drugs are associated with higher bleeding rates, consistent with the levels of platelet inhibition achieved by these drugs. Studies of patients treated with clopidogrel, which is associated with wide inter-individual variation in antiplatelet effect, suggest that platelet function testing may predict bleeding risk related to coronary artery bypass grafting (CABG) surgery and potentially guide the timing of surgery following discontinuation of clopidogrel. Similarly, some studies have demonstrated a relationship between clopidogrel response and bleeding in patients undergoing percutaneous coronary intervention (PCI), although other studies have not supported this. Carriage of the *17 allele of cytochrome P450 2C19, which is associated with gain of function and enhanced response to clopidogrel, seems to be associated with increased bleeding risk, although studies showing lack of apparent effect of loss-of-function alleles provide contradictory evidence. Further large studies are needed to guide best practice in the application of platelet function testing in the clinical management of patients treated with antiplatelet drugs in order to optimise individual care.
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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21
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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22
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Schoos M, Chandrasekhar J, Baber U, Bhasin A, Sartori S, Aquino M, Vogel B, Farhan S, Sorrentino S, Kini A, Kruckoff M, Moliterno D, Henry TD, Weisz G, Gibson CM, Iakovou I, Colombo A, Steg PG, Witzenbichler B, Chieffo A, Cohen D, Stuckey T, Ariti C, Dangas G, Pocock S, Mehran R. Causes, Timing, and Impact of Dual Antiplatelet Therapy Interruption for Surgery (from the Patterns of Non-adherence to Anti-platelet Regimens In Stented Patients Registry). Am J Cardiol 2017; 120:904-910. [PMID: 28778417 DOI: 10.1016/j.amjcard.2017.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 11/17/2022]
Abstract
Temporary interruption of dual antiplatelet therapy (DAPT) is not infrequently required in patients undergoing percutaneous coronary intervention (PCI). We sought to describe the procedures and outcomes associated with DAPT interruption in patients treated with DAPT following successful PCI from the Patterns of non-adherence to anti-platelet regimens in stented patients registry (n = 5018). DAPT interruption was prespecified as physician recommended cessation for <14 days. Of the study cohort, 490 patients (9.8%) experienced 594 DAPT interruptions over 2 years following PCI. Only 1 antiplatelet agent was interrupted in 57.2% cases and interruption was frequently recommended by noncardiologists (51.3%). Where type of surgery was reported, majority of DAPT interruptions occurred for minor surgery (68.4% vs 31.6%) and a similar cessation pattern of single versus dual antiplatelet cessation was observed regardless of minor or major surgery. Subsequent to DAPT interruption, 12 patients (2.4%) experienced 1 thrombotic event each, of which 5 (1.0%) occurred during the interruption period. All events occurred in patients who either stopped both agents (8 of 12) or clopidogrel-only (4 of 12), with no events occurring due to aspirin cessation alone. In conclusion, in the Patterns of Non-adherence to Anti-platelet Regiments in Stented Patients registry, 1 in 10 patients were recommended DAPT interruption for surgery within 2 years of PCI. Interruption was more common for a single agent rather than both antiplatelet agents regardless of severity of surgery, and was frequently recommended by noncardiologists. Only 1% of patients with DAPT interruption experienced a subsequent thrombotic event during the interruption period, which mainly occurred in patients stopping both antiplatelet agents.
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Affiliation(s)
- Mikkel Schoos
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Cardiology, Zealand University Hospital, Denmark
| | - Jaya Chandrasekhar
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Usman Baber
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aarti Bhasin
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Internal Medicine, Wyckoff Heights Medical Center, New York, New York
| | - Samantha Sartori
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa Aquino
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Birgit Vogel
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serdar Farhan
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sabato Sorrentino
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mitchell Kruckoff
- Department of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - David Moliterno
- Department of Cardiology, University of Kentucky, Lexington, Kentucky
| | - Timothy D Henry
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Giora Weisz
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - C Michael Gibson
- Department of Cardiology, Harvard Medical School, Cambridge, Massachusetts
| | - Ioannis Iakovou
- Department of Cardiology, Onassis Cardiac Surgery Centre, Athens, Greece
| | - Antonio Colombo
- Department of Cardiology, San Raffaele Hospital, Milan, Italy
| | - P Gabriel Steg
- Department of Cardiology, Hôpital Bichat-Claude Bernard, Paris, France
| | | | - Alaide Chieffo
- Department of Cardiology, San Raffaele Hospital, Milan, Italy
| | - David Cohen
- Department of Cardiology, St Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Thomas Stuckey
- Moses Cone Heart and Vascular Center, LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina
| | - Cono Ariti
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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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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Caporale R, Geraci G, Gulizia MM, Borzi M, Colivicchi F, Menozzi A, Musumeci G, Scherillo M, Ledda A, Tarantini G, Gerometta P, Casolo G, Formigli D, Romeo F, Di Bartolomeo R. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Association of Interventional Cardiology (SICI-GISE) and Italian Society of Cardiac Surgery (SICCH): clinical approach to pharmacologic pre-treatment for patients undergoing myocardial revascularization procedures. Eur Heart J Suppl 2017; 19:D151-D162. [PMID: 28751841 PMCID: PMC5520758 DOI: 10.1093/eurheartj/sux010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The wide availability of effective drugs in reducing cardiovascular events together with the use of myocardial revascularization has greatly improved the prognosis of patients with coronary artery disease. The combination of antithrombotic drugs to be administered before the knowledge of the coronary anatomy and before the consequent therapeutic strategies, can allow to anticipate optimal treatment, but can also expose the patients at risk of bleeding that, especially in acute coronary syndromes, can significantly weigh on their prognosis, even more than the expected theoretical benefit. In non ST-elevation acute coronary syndromes patients in particular, we propose a 'selective pre-treatment' with P2Y12 inhibitors, based on the ischaemic risk, on the bleeding risk and on the time scheduled for the execution of coronary angiography. Much of the problems concerning this issue would be resolved by an early access to coronary angiography, particularly for patients at higher ischaemic and bleeding risk.
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Affiliation(s)
- Roberto Caporale
- Interventional Cardiology Department, Ospedale Civile dell'Annunziata, Via Migliori 1, 87100 Cosenza, Italy
| | - Giovanna Geraci
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Mauro Borzi
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
| | | | - A. Menozzi
- Cardiology Unit, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | | | - Antonietta Ledda
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Giuseppe Tarantini
- Cardiological Sciences, Thoracic and Vascular Department, Università degli Studi, Padova, Italy
| | | | - Giancarlo Casolo
- Cardiology Department, Nuovo Ospedale Versilia, Lido di Camaiore, Lucca, Italy
| | - Dario Formigli
- Interventional Cardiology, A.O. G. Rummo, Benevento, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
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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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Aboul-Hassan SS, Stankowski T, Marczak J, Cichon R. What is the impact of preoperative aspirin administration on patients undergoing coronary artery bypass grafting? Interact Cardiovasc Thorac Surg 2017; 24:280-285. [PMID: 27702830 DOI: 10.1093/icvts/ivw317] [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: 09/24/2015] [Accepted: 08/24/2016] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether continuation of administration of preoperative aspirin until the day of coronary artery bypass grafting (CABG) could minimize postoperative mortality, prevalence of postoperative myocardial infarction (MI) with or without influence on postoperative bleeding, packed red blood cell (PRBC) transfusion and reoperation for bleeding. Altogether, 662 papers were found using the reported search, 7 of which represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Seven studies, included in this review, consisted of five meta-analyses and two randomized controlled trials. One meta-analysis, involving 27 533 patients submitted to CABG, showed that the administration of preoperative aspirin decreased postoperative 30-day mortality by 27%. Another meta-analysis, including 1437 patients, showed that preoperative aspirin decreased the incidence of perioperative MI by 44%, the effect being even more pronounced with low-dose aspirin, which reduced the prevalence of perioperative MI by 63%. One RCT showed that preoperative aspirin is associated with reduced long-term hazard of MI or repeated revascularization. Four meta-analyses and two RCTs showed that preoperative aspirin is associated with increased postoperative bleeding, PRBC transfusion and reoperation for bleeding. However, this was not the case with preoperative administration of low-dose aspirin. The results presented in these studies suggest that preoperative aspirin administration in patients undergoing CABG has a significant benefit in reducing the incidence of perioperative MI and 30-day mortality rate, as well as reduced long-term hazard of MI or repeated revascularization. At a higher dose (>100 mg/day), postoperative bleeding, PRBC transfusion and reoperation for bleeding increased. However, with low-dose aspirin (≤100 mg/day), these benefits were not at the expense of increased postoperative bleeding or transfusion.
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Affiliation(s)
| | - Tomasz Stankowski
- Department of Cardiac Surgery, MEDINET Heart Centre Ltd, Wroclaw, Poland
| | - Jakub Marczak
- Department of Cardiac Surgery, MEDINET Heart Centre Ltd, Wroclaw, Poland.,Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Romuald Cichon
- Department of Cardiac Surgery, Warsaw Medical University, Warsaw, Poland
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Tranexamic acid decreases the magnitude of platelet dysfunction in aspirin-free patients undergoing cardiac surgery with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2016; 27:855-861. [DOI: 10.1097/mbc.0000000000000485] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mahla E, Prueller F, Farzi S, Pregartner G, Raggam RB, Beran E, Toller W, Berghold A, Tantry US, Gurbel PA. Does Platelet Reactivity Predict Bleeding in Patients Needing Urgent Coronary Artery Bypass Grafting During Dual Antiplatelet Therapy? Ann Thorac Surg 2016; 102:2010-2017. [DOI: 10.1016/j.athoracsur.2016.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/23/2016] [Accepted: 05/02/2016] [Indexed: 11/25/2022]
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Preoperative and intraoperative variables to predict mortality: Which comes first, the chicken or the egg? J Thorac Cardiovasc Surg 2016; 153:1126-1127. [PMID: 27998610 DOI: 10.1016/j.jtcvs.2016.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/10/2016] [Indexed: 11/22/2022]
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Luni FK, Riaz H, Khan AR, Riaz T, Husnain M, Riaz IB, Khan MS, Taleb M, Kanjwal Y, Cooper CJ, Khuder SA. Clinical outcomes associated with per-operative discontinuation of aspirin in patients with coronary artery disease: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2016; 89:1168-1175. [PMID: 27663179 DOI: 10.1002/ccd.26807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 08/07/2016] [Accepted: 09/05/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative state is characterized by increased thrombotic risk by virtue of platelet activation. Whether aspirin ameliorates this risk in patients with established coronary artery disease undergoing cardiac or noncardiac surgery is unknown. We conducted a systematic review and meta-analysis to compare the risk of major adverse cardiac events (MACE) and the risk of bleeding in patients with early (3-5 or more days before surgery) vs. late discontinuation(<3-5 days)/no discontinuation of aspirin. METHODS Multiple databases were searched from inception of these databases until March 2015 to identify studies that reported discontinuation of aspirin in patients undergoing surgery. The outcomes measured were all cause mortality, nonfatal myocardial infarction and other relevant thrombotic events (MACE) which also may include, fatal and nonfatal MI, stent thrombosis and restenosis, stroke, perioperative cardiovascular complications (heart failure, MI, VTE, acute stroke) and perioperative bleeding during the perioperative period to up to 30 days after surgery. RESULTS A total of 1,018 titles were screened, after which six observational studies met the inclusion criteria. Our analysis suggests that there is no difference in MACE with planned discontinuation of aspirin (OR = 1.17, 95% CI = 0.76-1.81; P = 0.05; I2 = 55%). Early discontinuation of aspirin showed a decreased risk of peri-operative bleeding (OR 0.82, 95% CI = 0.67-0.99; P = 0.04; I2 = 42%). CONCLUSION Our analysis suggests that planned short-term discontinuation in the appropriate clinical setting appears to be safe in the correct clinical setting with no increased risk of thrombotic events and with a decreased risk of bleeding. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | | | | | - Talha Riaz
- Bronx Lebanon Hospital, New York, New York
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Agarwal S. Platelet function testing in cardiac surgery. Transfus Med 2016; 26:319-329. [PMID: 27535575 DOI: 10.1111/tme.12335] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/12/2016] [Accepted: 07/24/2016] [Indexed: 12/17/2022]
Abstract
Bleeding in cardiac surgery is known to cause increased morbidity and mortality. The rise in the use of anti-platelet medication has led to an increase in the number of patients presenting for cardiac surgery with platelet dysfunction, who are at a heightened risk of bleeding. However, the extent of platelet inhibition is well known to differ among individuals. In the past few years, a number of point-of-care platelet function testing devices, which may be able to assess platelet reactivity, have entered the market. This review will examine the devices most commonly studied and the evidence surrounding their use in cardiac surgery and their effect on blood loss.
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Affiliation(s)
- S Agarwal
- Department of Anaesthesia and Critical Care, Liverpool Heart and Chest Hospital, Liverpool, UK.
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Mahla E, Tantry US, Gurbel PA. To stop or continue aspirin before aortocoronary bypass operations-do we have enough evidence to adequately guide us? J Thorac Dis 2016; 8:E578-80. [PMID: 27501008 DOI: 10.21037/jtd.2016.05.19] [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)
- Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
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Byrne C, Tawfick W, Hynes N, Sultan S. Ten-year experience in subclavian revascularisation. A parallel comparative observational study. Vascular 2016; 24:378-82. [DOI: 10.1177/1708538115599699] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Subclavian stenosis has a prevalence of approximately 2% in the community, and 7% within a clinical population. It is closely linked with hypertension and smoking. There is a relative paucity of published data to inform clinicians on the optimal mode of treatment for subclavian artery stenosis. Objectives To compare clinical outcomes of subclavian bypass surgery with that of subclavian endovascular re-vascularisation. Endpoints were survival time, re-intervention-free survival, and symptom-free survival. Method In all, 21 subclavian interventions were performed from 2000 to 2010. We compared angioplasty vs angioplasty with stenting vs bypass. Results Technical success was 100% in all groups. Symptom-free survival, at 70 months, was 60% in the angioplasty group, 100% in the angioplasty and stenting group and 75% in the bypass group. Re-intervention rate was 40% in the angioplasty group, 0% in the angioplasty and stenting group and 25% in the bypass group. Median time for re-intervention was 9.5 months in angioplasty patients and 36 months in bypass patients ( p = 0.102). Target lesion revascularisation was 20.0% for angioplasty procedures, 16.67% for angioplasty and stenting and 25% for bypass procedures. Conclusion Angioplasty with stenting provides improved symptom-free survival and freedom from re-intervention in patients with symptomatic subclavian artery stenosis.
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Affiliation(s)
- C Byrne
- Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Republic of Ireland
| | - W Tawfick
- Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Republic of Ireland
| | - N Hynes
- Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Republic of Ireland
- Department of Vascular Surgery, Galway Clinic, Doughiska, Galway, Republic of Ireland
| | - S Sultan
- Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Republic of Ireland
- Department of Vascular Surgery, Galway Clinic, Doughiska, Galway, Republic of Ireland
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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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Imberger G, Gluud C, Boylan J, Wetterslev J. Systematic Reviews of Anesthesiologic Interventions Reported as Statistically Significant: Problems with Power, Precision, and Type 1 Error Protection. Anesth Analg 2016; 121:1611-22. [PMID: 26579662 DOI: 10.1213/ane.0000000000000892] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The GRADE Working Group assessment of the quality of evidence is being used increasingly to inform clinical decisions and guidelines. The assessment involves explicit consideration of all sources of uncertainty. One of these sources is imprecision or random error. Many published meta-analyses are underpowered and likely to be updated in the future. When data are sparse and there are repeated updates, the risk of random error is increased. Trial Sequential Analysis (TSA) is one of several methodologies that estimates this increased risk (and decreased precision) in meta-analyses. With nominally statistically significant meta-analyses of anesthesiologic interventions, we used TSA to estimate power and imprecision in the context of sparse data and repeated updates. METHODS We conducted a search to identify all systematic reviews with meta-analyses that investigated an intervention that may be implemented by an anesthesiologist during the perioperative period. We randomly selected 50 meta-analyses that reported a statistically significant dichotomous outcome in their abstract. We applied TSA to these meta-analyses by using 2 main TSA approaches: relative risk reduction 20% and relative risk reduction consistent with the conventional 95% confidence limit closest to null. We calculated the power achieved by each included meta-analysis, by using each TSA approach, and we calculated the proportion that maintained statistical significance when allowing for sparse data and repeated updates. RESULTS From 11,870 titles, we found 682 systematic reviews that investigated anesthesiologic interventions. In the 50 sampled meta-analyses, the median number of trials included was 8 (interquartile range [IQR], 5-14), the median number of participants was 964 (IQR, 523-1736), and the median number of participants with the outcome was 202 (IQR, 96-443). By using both of our main TSA approaches, only 12% (95% CI, 5%-25%) of the meta-analyses had power ≥ 80%, and only 32% (95% CI, 20%-47%) of the meta-analyses preserved the risk of type 1 error <5%. CONCLUSIONS Most nominally statistically significant meta-analyses of anesthesiologic interventions are underpowered, and many do not maintain their risk of type 1 error <5% if TSA monitoring boundaries are applied. Consideration of the effect of sparse data and repeated updates is needed when assessing the imprecision of meta-analyses of anesthesiologic interventions.
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Affiliation(s)
- Georgina Imberger
- From the *Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark; †Department of Anesthesia & Perioperative Medicine, Monash University, Melbourne, Australia; and ‡ Department of Anaesthesia, St. Vincent's Hospital, Dublin, Ireland
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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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Nenna A, Spadaccio C, Prestipino F, Lusini M, Sutherland FW, Beattie GW, Petitti T, Nappi F, Chello M. Effect of Preoperative Aspirin Replacement With Enoxaparin in Patients Undergoing Primary Isolated On-Pump Coronary Artery Bypass Grafting. Am J Cardiol 2016; 117:563-570. [PMID: 26721653 DOI: 10.1016/j.amjcard.2015.11.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
Management of preoperative antiplatelet therapy in coronary artery bypass grafting (CABG) is variable among surgeons: guidelines collide with prejudices because replacement of aspirin with low-molecular-weight heparin is still performed because of a presumed minor bleeding risk. This study aims to analyze postoperative bleedings and complications in patients scheduled for elective primary isolated on-pump CABG, depending on preoperative aspirin treatment or its replacement with enoxaparin. In this cohort study, we propensity score matched 200 patients in whom aspirin was stopped at least 5 days before CABG and replaced with enoxaparin and 200 patients who continued aspirin therapy until the day before surgery. Postoperative bleedings and complications were monitored during hospitalization. Among patients who continued aspirin treatment, mean overall bleeding was 701.0 ± 334.6 ml, whereas in the matched enoxaparin group, it was significantly greater (882.6 ± 64.6 ml, p value <0.001); this was associated with reduced postoperative complications, lower values of postoperative C-reactive protein in aspirin takers, and a presumed protective effect for statins. After propensity score adjustment, aspirin treatment carried a protective effect against major postoperative bleeding (odds ratio 0.312, p = 0.001). In conclusion, postoperative bleeding is reduced in patients who continued aspirin, likely due to a reduction in postoperative inflammation. The practice of empirically discontinuing aspirin and replacing it with enoxaparin before CABG should be abandoned. Patients with coronary artery disease referred to CABG should continue antiplatelet medications until the surgical procedure. Those results might be extended to patients under oral anticoagulant therapy requiring CABG.
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Lüscher TF. Use, complications, and outcome of novel therapeutic interventions. Eur Heart J 2016; 37:121-3. [DOI: 10.1093/eurheartj/ehv731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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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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Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2015; 37:267-315. [PMID: 26320110 DOI: 10.1093/eurheartj/ehv320] [Citation(s) in RCA: 4224] [Impact Index Per Article: 469.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Huang J, Donneyong M, Trivedi J, Barnard A, Chaney J, Dotson A, Raymer S, Cheng A, Liu H, Slaughter MS. Preoperative Aspirin Use and Its Effect on Adverse Events in Patients Undergoing Cardiac Operations. Ann Thorac Surg 2015; 99:1975-81. [DOI: 10.1016/j.athoracsur.2015.02.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 01/25/2015] [Accepted: 02/10/2015] [Indexed: 11/28/2022]
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Tsui PY, Cheung CW, Lee Y, Leung SWS, Ng KFJ. The effectiveness of low-dose desmopressin in improving hypothermia-induced impairment of primary haemostasis under influence of aspirin - a randomized controlled trial. BMC Anesthesiol 2015; 15:80. [PMID: 26017715 PMCID: PMC4469427 DOI: 10.1186/s12871-015-0061-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 05/21/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Mild hypothermia (34-35 °C) increases perioperative blood loss. Our previous studies showed that desmopressin could have in vitro beneficial effects on hypothermia-induced primary haemostasis impairment. In this study, we investigate the in vitro effects of desmopressin on hypothermia-induced primary haemostasis impairment under the influence of aspirin in healthy volunteers. METHODS Sixty healthy volunteers were randomly allocated to taking aspirin 100 mg or placebo for three days. On the sixth day blood samples were taken before and after the injection of desmopressin (1.5 microgram or 5 microgram) or normal saline subcutaneously. Measurements including Platelet Function Analyzer (PFA-100®) closure times, plasma von Willebrand Factor antigen, haemoglobin and platelet levels were made at 32 °C and 37 °C respectively. RESULTS Collagen/epinephrine closure time (EPICT) was significantly prolonged by 21.13 % (95 %CI 2.34-39.74 %, p = 0.021) in aspirin group at 37 °C. While hypothermia alone prolonged both collagen/adenosine diphosphate (ADPCT) and EPICT by 17.63 % (95 %CI 13.5-20.85 %, p < 0.001) and 8.0 % (95 %CI 6.38-10.04 %, p = 0.024) respectively, addition of aspirin only further prolonged EPICT by 19.9 % (95 %CI 3.32-36.49 %, p = 0.013). In aspirin group, desmopressin 1.5 microgram and 5 microgram significantly reduced ADPCT to below baseline levels at 37 °C (p = 0.025 and <0.001 respectively), whereas reduction in EPICT was seen with desmopressin 5 microgram (p =0.008). The effect was less pronounced at 32 °C, with a significant reduction in EPICT obtained with a dosage of 5 microgram only (p = 0.011). CONCLUSION It was shown that aspirin could further potentiate the hypothermia-induced closure time prolongations. Low dose desmopressin (1.5 microgram) reduced PFA-100® closure times towards baseline. A higher dosage (5 microgram) further reduced the closure times below baseline. Therefore low dose desmopressin (1.5 microgram) might have the potential to correct hypothermia-induced primary haemostasis impairment under the influence of aspirin during the perioperative period. TRIAL REGISTRATION ClinicalTrials.gov: NCT01382134.
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Affiliation(s)
- Pui Yee Tsui
- Department of Anaesthesia, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, SAR, China.
| | - Chi Wai Cheung
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
| | - Yvonne Lee
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
| | - Susan Wai Sum Leung
- Department of Pharmacology & Pharmacy, The University of Hong Kong, Hong Kong, SAR, China.
| | - Kwok Fu Jacobus Ng
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
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Siller-Matula JM, Petre A, Delle-Karth G, Huber K, Ay C, Lordkipanidzé M, De Caterina R, Kolh P, Mahla E, Gersh BJ. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:753-770. [DOI: 10.1177/2048872615585516] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Alexandra Petre
- Department of Cardiology, Medical University of Vienna, Austria
| | | | - Kurt Huber
- 3rd Medical Department of Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria
| | - Marie Lordkipanidzé
- Faculty of Pharmacy, University of Montreal; Research Center, Montreal Heart Institute, Canada
| | - Raffaele De Caterina
- Institute of Cardiology, ‘G d’Annunzio’ University – Chieti-Pescara, Chieti, Italy
| | - Philippe Kolh
- Department of Cardiothoracic Surgery, University Hospital of Liege, Belgium
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Austria
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, College of Medicine Rochester, USA
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Keeler BD, Simpson JA, Fox SC, Stavrou CL, Briggs RA, Patel P, Heptinstall S, Acheson AG. An observational study investigating the effect of platelet function on outcome after colorectal surgery. Int J Surg 2015; 17:28-33. [DOI: 10.1016/j.ijsu.2015.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 02/08/2015] [Accepted: 02/28/2015] [Indexed: 10/23/2022]
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Kempfert J, Meyer A, Arsalan M, Walther T. Perioperativer Umgang mit moderner Thrombozytenaggregationshemmung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-014-1121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- Thomas F Lüscher
- Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
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