1
|
Zhu Y, Zhang W, Dimagli A, Han L, Cheng Z, Mei J, Chen X, Wang X, Zhou Y, Xue Q, Hu J, Tang M, Wang R, Song Y, Kang L, Redfors B, Gaudino M, Zhao Q. Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial. BMJ 2024; 385:e075707. [PMID: 38862179 PMCID: PMC11165385 DOI: 10.1136/bmj-2023-075707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVE To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting. DESIGN Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial. SETTING Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021. PARTICIPANTS 500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial. INTERVENTIONS Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians. MAIN OUTCOME MEASURES The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings. RESULTS Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses. CONCLUSIONS Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy. TRIAL REGISTRATION NCT03987373ClinicalTrials.gov NCT03987373.
Collapse
Affiliation(s)
- Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wei Zhang
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Arnaldo Dimagli
- Department of Cardio-thoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Lin Han
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Naval Medical University (Shanghai Changhai Hospital), Shanghai, 200433, China
| | - Zhaoyun Cheng
- Department of Cardiac Surgery, Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xin Chen
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Xiaowei Wang
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Yanzai Zhou
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qing Xue
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Naval Medical University (Shanghai Changhai Hospital), Shanghai, 200433, China
| | - Junlong Hu
- Department of Cardiac Surgery, Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, China
| | - Min Tang
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Rui Wang
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Yuanyuan Song
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Lei Kang
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, 41345, Sweden
| | - Mario Gaudino
- Department of Cardio-thoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| |
Collapse
|
2
|
Khalil J, Dimofte T, Roberts T, Keith M, Amaradasa K, Hindle MS, Bancroft S, Hutchinson JL, Naseem K, Johnson T, Mundell SJ. Ticagrelor inverse agonist activity at the P2Y 12 receptor is non-reversible versus its endogenous agonist adenosine 5´-diphosphate. Br J Pharmacol 2024; 181:21-35. [PMID: 37530222 PMCID: PMC10953389 DOI: 10.1111/bph.16204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 05/12/2023] [Accepted: 07/02/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Ticagrelor is labelled as a reversible, direct-acting platelet P2Y12 receptor (P2Y12 R) antagonist that is indicated clinically for the prevention of thrombotic events in patients with acute coronary syndrome (ACS). As with many antiplatelet drugs, ticagrelor therapy increases bleeding risk in patients, which may require platelet transfusion in emergency situations. The aim of this study was to further examine the reversibility of ticagrelor at the P2Y12 R. EXPERIMENTAL APPROACH Studies were performed in human platelets, with P2Y12 R-stimulated GTPase activity and platelet aggregation assessed. Cell-based bioluminescence resonance energy transfer (BRET) assays were undertaken to assess G protein-subunit activation downstream of P2Y12 R activation. KEY RESULTS Initial studies revealed that a range of P2Y12 R ligands, including ticagrelor, displayed inverse agonist activity at P2Y12 R. Only ticagrelor was resistant to washout and, in human platelet and cell-based assays, washing failed to reverse ticagrelor-dependent inhibition of ADP-stimulated P2Y12 R function. The P2Y12 R agonist 2MeSADP, which was also resistant to washout, was able to effectively compete with ticagrelor. In silico docking revealed that ticagrelor and 2MeSADP penetrated more deeply into the orthosteric binding pocket of the P2Y12 R than other P2Y12 R ligands. CONCLUSION AND IMPLICATIONS Ticagrelor binding to P2Y12 R is prolonged and more akin to that of an irreversible antagonist, especially versus the endogenous P2Y12 R agonist ADP. This study highlights the potential clinical need for novel ticagrelor reversal strategies in patients with spontaneous major bleeding, and for bleeding associated with urgent invasive procedures.
Collapse
Affiliation(s)
- Jawad Khalil
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Tudor Dimofte
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Timothy Roberts
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Michael Keith
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Kumuthu Amaradasa
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Matthew S. Hindle
- Leeds Institute of Genetics, Health and Therapeutics (LIGHT)University of LeedsLeedsUK
| | - Sukhinder Bancroft
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - James L. Hutchinson
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| | - Khalid Naseem
- Leeds Institute of Genetics, Health and Therapeutics (LIGHT)University of LeedsLeedsUK
| | | | - Stuart J. Mundell
- School of Physiology, Pharmacology and Neuroscience, Faculty of Life SciencesUniversity of BristolBristolUK
| |
Collapse
|
3
|
Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
Collapse
Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
4
|
Dzhioeva ON, Rogozhkina EA, Drapkina OM. Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2022-12-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Currently, antithrombotic therapy is the basis of the pathogenetic treatment of many cardiovascular diseases, such as coronary heart disease, stroke, peripheral vascular disease, as well as mechanical heart valves, heart rhythm disturbances, venous thromboembolism. At the same time, chronic use of antiplatelet and/or anticoagulant drugs is a complicating factor in invasive and surgical procedures, as it increases the risk of bleeding. In this regard, a fundamentally important and complex question arises: how to minimize the risk of periprocedural bleeding without exposing the patient to an increased risk of ischemic and thromboembolic complications? Perioperative management of patients who take antithrombotic drugs for a long time is a complex problem that depends on many factors - the risk of surgery, anesthesia, cardiovascular risks, and the urgency of surgery. Each clinical situation should be assessed individually, collegially, with the participation of surgeons, anesthesiologists, and therapists. The introduction of a checklist into clinical practice for each planned surgical patient will allow us to calculate the individual risk of bleeding and thromboembolic complications, and provide an optimal preventive strategy for perioperative management of the patient. The algorithms and schemes presented in the article for the perioperative management of patients with non-cardiac interventions are aimed at standardizing the management of patients before non-cardiac surgical interventions, which will reduce hemorrhagic risks in the presence of the necessary antithrombotic therapy.
Collapse
Affiliation(s)
- O. N. Dzhioeva
- National Medical Research Center for Therapy and Preventive Medicine;
A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| | - E. A. Rogozhkina
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine;
A.I. Yevdokimov Moscow State University of Medicine and Dentistry
| |
Collapse
|
5
|
Tripathi R, Morales J, Lee V, Gibson CM, Mack MJ, Schneider DJ, Douketis J, Sellke FW, Ohman ME, Thourani VH, Storey RF, Deliargyris EN. Antithrombotic drug removal from whole blood using Haemoadsorption with a porous polymer bead sorbent. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:847-856. [PMID: 35657375 PMCID: PMC9716861 DOI: 10.1093/ehjcvp/pvac036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 12/29/2022]
Abstract
AIM To evaluate the ability of the DrugSorb™-AntiThrombotic Removal (ATR) haemoadsorption device utilizing porous polymer bead sorbent technology to remove three commonly used antithrombotic drugs from whole blood. METHODS AND RESULTS We evaluated the removal of apixaban, rivaroxaban, and ticagrelor by the DrugSorb-ATR haemoadsorption device in a benchtop clinical scale model using bovine whole blood. Blood spiked at clinically relevant concentrations of an antithrombotic agent was continuously circulated through a 300-mL DrugSorb-ATR haemoadsorption device at a flow rate of 300 mL/min. Drug concentration was monitored over 6 h to evaluate drug removal. Results were compared with a control circuit without the haemoadsorption device. Removal rates at 30, 60, 120, and 360 minutes were: apixaban: 81.5%, 96.3%, 99.3% >99.8%; rivaroxaban: 80.7%, 95.1%, 98.9%, >99.5%; ticagrelor: 62.5%; 75%, 86.6%, >95% (all P <0.0001 vs. control). Blood pH and haematological parameters were not significantly affected by the DrugSorb-ATR haemoadsorption device when compared with the control circuit. CONCLUSION DrugSorb-ATR efficiently removes apixaban, rivaroxaban, and ticagrelor in a clinical-scale benchtop recirculation circuit with the bulk of removal occurring in the first 60 minutes. The clinical implications of these findings are currently investigated in patients undergoing on-pump cardiothoracic surgery in two US pivotal trials (ClinicalTrials.gov Identifiers: NCT04976530 and NCT05093504).
Collapse
Affiliation(s)
- Ritu Tripathi
- Corresponding Author: Tel: +1-732-329-8885; FAX: +1-732-329-8650;
| | | | - Victoria Lee
- CytoSorbents Medical Inc.305 College Road E, Princeton, NJ-08540, USA
| | - C Michael Gibson
- Department of Medicine at Beth Israel Deaconess Medical Center, The Baim Institute and Harvard Medical School, Boston, MA-02215, USA
| | - Michael J Mack
- Baylor Scott & White Health, Baylor Scott & White Research Institute, Dallas, TX-75093, USA
| | - David J Schneider
- Department of Medicine, Cardiovascular Research Institute, University of Vermont, Burlington VT-05401, USA
| | - James Douketis
- Vascular Medicine and General Internal Medicine, St. Joseph's Healthcare Hamilton, McMaster University, ON-L9C 0E3, Canada
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University, Providence RI-02903, USA
| | - Magnus E Ohman
- Duke Clinical Research Institute, Duke Heart Center, Duke Program for Advanced Coronary Disease, Duke University Medical Center, Durham, NC-27701, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA-30309, USA
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK
| | | |
Collapse
|
6
|
Moster M, Bolliger D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00511-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose of Review
Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.
Recent Findings
Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.
Summary
Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.
Collapse
|
7
|
|
8
|
Qu J, Zhang H, Rao C, Chen S, Zhao Y, Sun H, Song Y, Liu S, Wang L, Feng W, Wang S, Hu S, Zheng Z. Dual Antiplatelet Therapy with Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients Undergoing Coronary Artery Bypass Graft Surgery. J Am Heart Assoc 2021; 10:e020413. [PMID: 33998246 PMCID: PMC8483527 DOI: 10.1161/jaha.120.020413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The optimal antiplatelet therapy after coronary artery bypass grafting remains unclear. We evaluated the association of dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin and clinical outcomes among patients undergoing coronary artery bypass grafting. Methods and Results A total of 18 069 consecutive patients who underwent primary isolated coronary artery bypass grafting between 2013 and 2017 were identified from a contemporary registry, and 10 854 (60.1%) received DAPT with clopidogrel plus aspirin as determined by claimed prescriptions after surgery. Cox regression models with inverse probability of treatment weighting were used to examine the associations between DAPT and outcomes. Patients who received DAPT, compared with those who received aspirin monotherapy, had a lower incidence of a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 6 months (2.9% versus 4.2%; inverse probability of treatment weighting-adjusted hazard ratio [HR], 0.65; 95% CI, 0.55-0.77; P<0.001) as well as death (HR, 0.61; 95% CI, 0.41-0.90), myocardial infarction (HR, 0.55; 95% CI, 0.40-0.74), and stroke (HR, 0.58; 95% CI, 0.46-0.74). The incidence of major bleeding did not differ significantly between the 2 groups (HR, 1.11; 95% CI, 0.69-1.78). Similar results were noted across multiple subgroups as well as when using different analytic methods. Conclusions Among patients undergoing coronary artery bypass grafting, DAPT with clopidogrel plus aspirin as secondary prevention was associated with reduced risk of major adverse cardiovascular and cerebrovascular events within 6 months as compared with aspirin monotherapy, and there was no significant increase in major bleeding.
Collapse
Affiliation(s)
- Jianyu Qu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Heng Zhang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Chenfei Rao
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Sipeng Chen
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Information Center Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Yan Zhao
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Hansong Sun
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Yunhu Song
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Sheng Liu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Liqing Wang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Wei Feng
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Shuiyun Wang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Shengshou Hu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| |
Collapse
|
9
|
Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
Collapse
Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| |
Collapse
|
10
|
Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
Collapse
Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
11
|
Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
|
12
|
Dimitriadis S, Qian E, Irvine A, Harky A. Secondary Prevention Medications Post Coronary Artery Bypass Grafting Surgery-A Literature Review. J Cardiovasc Pharmacol Ther 2021; 26:310-320. [PMID: 33514291 DOI: 10.1177/1074248420987445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Secondary prevention after coronary artery bypass graft (CABG) surgery is imperative in slowing the progression of atherosclerosis in both native and grafted vessels. Aspirin and statins remain the key medications for all patients without significant contraindications. The evidence for dual antiplatelet therapy with clopidogrel is less convincing, but there is hope for newer antiplatelet agents, such as ticagrelor. Meanwhile, β-blockers and angiotensin converting enzyme inhibitors might only offer benefits to specific sub-groups. Post-CABG patients appear to have different medication needs to the general cardiovascular patient and respond differently. In this review, we cover the drug regimens proposed by recent guidelines and the evidence behind their use. Assessing the evidence behind these recommendations, we find that there is an unmet need in some areas for robust population-specific evidence. We hope that future research will address this gap.
Collapse
Affiliation(s)
- Stavros Dimitriadis
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Evelyn Qian
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Amy Irvine
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, 8959Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| |
Collapse
|
13
|
Rocha-Gomes JN, Saraiva FA, Cerqueira RJ, Moreira R, Ferreira AF, Barros AS, Amorim MJ, Pinho P, Lourenço AP, Leite-Moreira AF. Early dual antiplatelet therapy versus aspirin monotherapy after coronary artery bypass surgery: survival and safety outcomes. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:662-672. [DOI: 10.23736/s0021-9509.20.11306-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
14
|
Varma PK, Ahmed H, Krishna N, Jose R, Gopal K, Mathew OP, Jayant A. Bleeding complications after dual antiplatelet therapy with ticagrelor versus dual antiplatelet therapy with clopidogrel-a propensity-matched comparative study of two antiplatelet regimes in off-pump coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 2020; 37:27-37. [PMID: 33442205 DOI: 10.1007/s12055-020-01052-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/30/2020] [Accepted: 09/07/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose Ticagrelor combined with aspirin had shown better saphenous vein graft patency than aspirin with clopidogrel after off-pump coronary artery bypass grafting. However, the safety of this drug in regard to bleeding complications remains unknown. The aim of our study was to assess the bleeding complications of dual antiplatelet therapy with aspirin and ticagrelor compared with aspirin and clopidogrel within the first 3 months after off-pump surgery. Methods Three hundred eighty-two consecutive patients who were prescribed aspirin with ticagrelor (ticagrelor group) were compared with 660 patients who received aspirin and clopidogrel (clopidogrel group). After propensity matching, 144 patients in each group were compared for bleeding events and major adverse cardiac and cerebral events. Major bleeding was defined as composite outcome of re-exploration for bleeding, any fatal bleeding, intracranial bleeding, and any bleeding requiring hospitalization. Results Patients in the ticagrelor group had more incidence of re-exploration for bleeding (p = 0.042), pericardial effusion requiring drainage (p = 0.007), readmissions (p < 0.01), gastrointestinal bleeding (p = 0.01), and major bleeding (5.8% vs. 2.1%, p < 0.01, OR 2.8 (1.43-5.58)). After propensity analysis, gastrointestinal bleed (p = 0.024), major bleeding (7.6% vs.1.4%, p < 0.001, OR 5.8 (1.28-26.97)), length of ICU stay (p = 0.039), and readmissions (p = 0.003, OR 11.83 (1.51-92.86)) were more in the ticagrelor group. Major adverse cardiac and cerebral events were similar between the groups. Conclusion Dual antiplatelet therapy with aspirin and ticagrelor increased gastrointestinal bleeding events, major bleeding events, and readmission rates compared with aspirin and clopidogrel after off-pump coronary artery bypass grafting.
Collapse
Affiliation(s)
- Praveen Kerala Varma
- Department of Cardiothoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Hisham Ahmed
- Department of Cardiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Department of Cardiothoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Rajesh Jose
- Department of Cardiothoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Kirun Gopal
- Department of Cardiothoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Department of Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| |
Collapse
|
15
|
Bolliger D, Lancé MD, Siegemund M. Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1049-1059. [PMID: 32807601 DOI: 10.1053/j.jvca.2020.07.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
Although most physicians are comfortable managing the limited anticoagulant effect of aspirin, the recent administration of potent P2Y12 receptor inhibitors in patients undergoing cardiac surgery remains a dilemma. Guidelines recommend discontinuation of potent P2Y12 inhibitors 5- to- 7 days before surgery to reduce the risk of postoperative hemorrhage. Such a strategy might not be feasible before urgent surgery, due to ongoing myocardial ischemia or in patients at high risk for thromboembolic events. Recently, different point-of-care devices to assess functional platelet quality have become available for clinical use. The aim of this narrative review was to evaluate the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients treated with antiplatelets, including aspirin or P2Y12 receptor inhibitors, undergoing cardiac surgery. No objective superiority of one point-of-care device over another was found in a large meta-analysis. Their accuracy and reliability are generally limited in the perioperative period. In particular, preoperative platelet function testing has been used to assess platelet contribution to bleeding after cardiac surgery. However, predictive values for postoperative hemorrhage and transfusion requirements are low, and there is a significant variability between and within these tests. Further, platelet function monitoring has been used to optimize the preoperative waiting period after cessation of dual antiplatelet therapy before urgent cardiac surgery. Furthermore, studies assessing their value in therapeutic decisions in bleeding patients after cardiac surgery are scarce. A general and liberal use of perioperative platelet function testing is not yet recommended.
Collapse
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Marcus D Lancé
- Department of Anesthesiology, Intensive Care Unit and Perioperative Medicine, Weill-Cornell Medicine-Qatar, Hamad Medical Corporation, Doha, Qatar
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
16
|
Antonopoulos AS, Odutayo A, Oikonomou EK, Trivella M, Petrou M, Collins GS, Antoniades C. Development of a risk score for early saphenous vein graft failure: An individual patient data meta-analysis. J Thorac Cardiovasc Surg 2020; 160:116-127.e4. [PMID: 31606176 PMCID: PMC7322547 DOI: 10.1016/j.jtcvs.2019.07.086] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/24/2019] [Accepted: 07/08/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Early saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery). METHODS Published literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively. RESULTS In aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716). CONCLUSIONS From a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies.
Collapse
Affiliation(s)
- Alexios S Antonopoulos
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ayodele Odutayo
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Evangelos K Oikonomou
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Marialena Trivella
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Mario Petrou
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom.
| |
Collapse
|
17
|
Javanbakht M, Trevor M, Rezaei Hemami M, Rahimi K, Branagan-Harris M, Degener F, Adam D, Preissing F, Scheier J, Cook SF, Mortensen E. Ticagrelor Removal by CytoSorb ® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis. PHARMACOECONOMICS - OPEN 2020; 4:307-319. [PMID: 31620999 PMCID: PMC7248150 DOI: 10.1007/s41669-019-00183-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Acute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb®, a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery. OBJECTIVE The aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK. METHODS A de novo decision analytic model, based on current treatment pathways, was developed to estimate the short- and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters. RESULTS In emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators-delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53-77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit. CONCLUSIONS The implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.
Collapse
Affiliation(s)
- Mehdi Javanbakht
- Optimax Access UK Ltd, Market Access Consultancy, 20 Forth Banks Tower, Newcastle upon Tyne, NE1 3PN, UK.
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK.
| | | | | | - Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Michael Branagan-Harris
- Device Access UK Ltd, Market Access Consultancy, University of Southampton Science Park, Chilworth Hampshire, UK
| | | | | | | | | | | | | |
Collapse
|
18
|
Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:429-450. [PMID: 32082905 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
Collapse
|
19
|
Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3700] [Impact Index Per Article: 925.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
20
|
Beverly A, Ong G, Wilkinson KL, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in adults undergoing cardiac surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anair Beverly
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Giok Ong
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Kirstin L Wilkinson
- Southampton University NHS Hospital; Paediatric and Adult Cardiothoracic Anaesthesia; Tremona Road Southampton UK SO16 6YD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Nicky J Welton
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
| |
Collapse
|
21
|
Knapik P, Knapik M, Zembala MO, Przybyłowski P, Nadziakiewicz P, Hrapkowicz T, Cieśla D, Deja M, Suwalski P, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M, Anisimowicz L, Biederman A, Borkowski D, Brykczyński M, Bugajski P, Cholewiński P, Cichoń R, Cisowski M, Deja M, Dziatkowiak A, Gryszko LA, Gburek T, Haponiuk I, Hendzel P, Hirnle T, Jabłonka S, Jarmoszewicz K, Jasiński M, Jaszewski R, Jemielity M, Kalawski R, Kapelak B, Kaperczak J, Karolczak MA, Krejca M, Kustrzycki W, Kuśmierczyk M, Kwinecki P, Maruszewski B, Missima M, Ogorzeja JJMW, Pająk J, Pawliszak W, Pietrzyk E, Religa G, Rogowski J, Różański J, Sadowski J, Sharma G, Skalski J, Skiba J, Stążka J, Stępiński P, Suwalski K, Suwalski P, Tobota Z, Tułecki Ł, Widenka K, Wojtalik M, Woś S, Zembala M, Żelazny P. In-hospital and mid-term outcomes in patients reoperated on due to bleeding following coronary artery surgery (from the KROK Registry). Interact Cardiovasc Thorac Surg 2019; 29:237–243. [PMID: 30968119 DOI: 10.1093/icvts/ivz089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Surgical re-exploration due to postoperative bleeding that follows coronary artery surgery is associated with significant morbidity and mortality. The aim of this study was to assess a relationship between re-exploration, major postoperative complications, in-hospital mortality and mid-term outcomes in patients following coronary surgery, on the basis of nationwide registry data. METHODS We identified all consecutive patients enrolled in Polish National Registry of Cardiac Surgical Procedures (KROK Registry) who underwent isolated coronary surgery between January 2012 and December 2014. Preoperative data, major postoperative complications, hospital mortality and mid-term all-cause mortality were, respectively, analysed. Comparisons were performed in all patients, low-risk patients (EuroSCORE II < 2%, males, aged 60-70 years) and propensity-matched patients. The starting point for follow-up was the date of hospital discharge. RESULTS Among 41 353 analysed patients, 1406 (3.4%) underwent re-exploration. Reoperated patients had more comorbidities, more frequent major postoperative complications, higher in-hospital mortality (13.2% vs 1.8%, P < 0.001) and higher mid-term mortality in survivors (P < 0.001). In the low-risk population, 3.0% of patients underwent re-exploration. Reoperated low-risk patients and propensity-matched patients also had more frequent major postoperative complications and higher in-hospital mortality, but mid-term mortality in survivors was similar. In a multivariable analysis, re-exploration was an independent predictor of death and all major postoperative complications. CONCLUSIONS Surgical re-exploration due to postoperative bleeding following coronary artery surgery carries a high risk of perioperative mortality and is linked to major postoperative complications. Among patients who survive to hospital discharge, mid-term mortality is associated primarily with preoperative comorbidities.
Collapse
Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Małgorzata Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał O Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Division of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Centre for Heart Diseases, Zabrze, Poland.,First Department of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Upper-Silesian Medical Centre, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Jasiński
- Department of Cardiac Surgery, University Teaching Hospital, Wrocław, Poland
| | - Zdzisław Tobota
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan J Maruszewski
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Gupta S, Belley-Cote EP, Agahi P, Basha A, Jaffer I, Mehta S, Schwalm JD, Whitlock RP. Antiplatelet Therapy and Coronary Artery Bypass Grafting: Analysis of Current Evidence With a Focus on Acute Coronary Syndrome. Can J Cardiol 2019; 35:1030-1038. [DOI: 10.1016/j.cjca.2019.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 01/31/2023] Open
|
23
|
Schunkert H, Boening A, von Scheidt M, Lanig C, Gusmini F, de Waha A, Kuna C, Fach A, Grothusen C, Oberhoffer M, Knosalla C, Walther T, Danner BC, Misfeld M, Zeymer U, Wimmer-Greinecker G, Siepe M, Grubitzsch H, Joost A, Schaefer A, Conradi L, Cremer J, Hamm C, Lange R, Radke PW, Schulz R, Laufer G, Grieshaber P, Pader P, Attmann T, Schmoeckel M, Meyer A, Ziegelhöffer T, Hambrecht R, Kastrati A, Sandner SE. Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: the TiCAB trial. Eur Heart J 2019; 40:2432-2440. [DOI: 10.1093/eurheartj/ehz185] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/19/2018] [Accepted: 03/12/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Aims
The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared the efficacy of ticagrelor and aspirin after CABG.
Methods and results
We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group [hazard ratio 1.19; 95% confidence interval (CI) 0.87–1.62; P = 0.28]. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53–1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38–1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36–1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70–2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71–1.92; P = 0.53).
Conclusion
In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated.
ClinicalTrials.gov Identifier
NCT01755520.
Collapse
Affiliation(s)
- Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, Justus-Liebig University Gießen, Ludwigstraße 23, Gießen, Germany
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Clarissa Lanig
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
| | - Friederike Gusmini
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
| | - Antoinette de Waha
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
| | - Constantin Kuna
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
| | - Andreas Fach
- Department of Cardiology and Angiology, Klinikum Links der Weser, Senator-Weßling-Straße 1, Bremen, Germany
| | - Christina Grothusen
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Arnold-Heller-Straße 3, Kiel, Germany
| | - Martin Oberhoffer
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Lohmühlenstraße 5, Hamburg, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Augustenburger Platz 1, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Benekestraße 2-8, Bad Nauheim, Germany
| | - Bernhard C Danner
- Department of Thoracic and Cardiovascular Surgery, University Medical Center, Robert-Koch-Straße 40, Göttingen, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Strümpellstraße 39, Leipzig, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Bremserstraße 79, Ludwigshafen, Germany
| | - Gerhard Wimmer-Greinecker
- Department for Cardiothoracic Surgery, Heart and Vessel Center Bad Bevensen, Römstedter Straße 25, Bad Bevensen, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Hugstetter Straße 55, Freiburg, Germany
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany
| | - Alexander Joost
- Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, Lübeck, Germany
| | - Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Arnold-Heller-Straße 3, Kiel, Germany
| | - Christian Hamm
- Justus-Liebig University Gießen, Kerckhoff Campus, Ludwigstraße 23, Gießen, Germany
- DZHK (German Center for Cardiovascular Research), partner site Rhein-Main, Rhein-Main, Germany
| | - Rüdiger Lange
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Peter W Radke
- Department of Internal Medicine-Cardiology, Schön Klinik Neustadt SE & Co. KG, Am Kiebitzberg 10, Neustadt, Germany
| | - Rainer Schulz
- Institute of Physiology, Justus-Liebig University Gießen, Aulweg 129, Gießen, Germany
| | - Günther Laufer
- Division of Cardiac Surgery, Medical University Vienna, Spitalgasse 23, Wien, Austria
| | - Philippe Grieshaber
- Department of Cardiovascular Surgery, Justus-Liebig University Gießen, Ludwigstraße 23, Gießen, Germany
| | - Philip Pader
- Department of Cardiology and Angiology, Klinikum Links der Weser, Senator-Weßling-Straße 1, Bremen, Germany
| | - Tim Attmann
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Arnold-Heller-Straße 3, Kiel, Germany
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Lohmühlenstraße 5, Hamburg, Germany
| | - Alexander Meyer
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Augustenburger Platz 1, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Tibor Ziegelhöffer
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Benekestraße 2-8, Bad Nauheim, Germany
| | - Rainer Hambrecht
- Department of Cardiology and Angiology, Klinikum Links der Weser, Senator-Weßling-Straße 1, Bremen, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Sigrid E Sandner
- Division of Cardiac Surgery, Medical University Vienna, Spitalgasse 23, Wien, Austria
| |
Collapse
|
24
|
|
25
|
Frelinger AL. Platelet Function Testing in Clinical Research Trials. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
26
|
Cardoso R, Knijnik L, Whelton SP, Rivera M, Gluckman TJ, Metkus TS, Blumenthal RS, McEvoy JW. Dual versus single antiplatelet therapy after coronary artery bypass graft surgery: An updated meta-analysis. Int J Cardiol 2018; 269:80-88. [DOI: 10.1016/j.ijcard.2018.07.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/30/2018] [Accepted: 07/17/2018] [Indexed: 12/20/2022]
|
27
|
Redondo Palacios A, Muñoz Pérez R, López Menéndez J, Varela Barca L, Miguelena Hycka J, Martín García M, Fajardo Rodríguez E, Rodríguez-Roda Stuart J, Centella Hernández T. Manejo del tratamiento antitrombótico en cirugía cardiovascular: puntualización sobre el Documento de Consenso acerca del manejo perioperatorio y periprocedimiento del tratamiento antitrombótico. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
28
|
Zafar MU, Smith DA, Baber U, Sartori S, Chen K, Lam DW, Linares-Koloffon CA, Rey-Mendoza J, Jimenez Britez G, Escolar G, Fuster V, Badimon JJ. Impact of Timing on the Functional Recovery Achieved With Platelet Supplementation After Treatment With Ticagrelor. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005120. [PMID: 28768756 DOI: 10.1161/circinterventions.117.005120] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/30/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND American College of Cardiology/American Heart Association guidelines advise waiting 5 to 7 days before operating on P2Y12 inhibitor-treated acute coronary syndrome patients, to allow dissipation of its antiplatelet effects. Platelet transfusion is often used to restore hemostasis during operations, but its effectiveness and optimal timing are unclear. We investigated the degree of functional gains obtained from platelet supplementation after loading and maintenance of dual antiplatelet therapy with ticagrelor and the influence of timing on this strategy. METHODS AND RESULTS After baseline platelet testing (Multiplate Analyzer and VerifyNow), cardiovascular disease patients (n=20; 56.9±7.9 years; 65% men; 75% diabetic) received dual antiplatelet therapy as a single loading dose (ticagrelor 180 mg plus aspirin 325 mg) and as daily/maintenance treatment for 5 to 7 days (maintenance therapy: ticagrelor 90 mg BID plus aspirin 81 mg QD). At 4, 6, 24, and 48 hours from (last) dosing, patients' blood samples were supplemented with concentrated platelets from healthy donors in vitro, raising platelet counts by 0% (unsupplemented control), 25%, 50%, and 75%, and the function retested. Reactivity in supplemented samples was compared with respective 0% sample and with the pretreatment baseline. Results under loading dose and maintenance therapy regimens were nearly identical. Platelet reactivity was higher (P<0.05) in nearly all supplemented samples versus respective controls. Aggregations with supplementation were 59% to 79% of baseline at 24 hours and equal to baseline at 48 hours. CONCLUSIONS Platelet reactivity of ticagrelor-treated patients can be restored using concentrated platelets after a loading dose/maintenance therapy in a time-dependent manner under in vitro testing. Although statistically significant improvements are evident 6 hours after (last) dosing, ≥24 hours maybe needed for clinically meaningful restoration in platelet function. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT02201394.
Collapse
Affiliation(s)
- M Urooj Zafar
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Donald A Smith
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Usman Baber
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Samantha Sartori
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Kevin Chen
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - David W Lam
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Carlos A Linares-Koloffon
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Juan Rey-Mendoza
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Gustavo Jimenez Britez
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Gines Escolar
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Valentin Fuster
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.)
| | - Juan J Badimon
- From the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (M.U.Z., D.A.S., U.B., S.S., K.C., D.W.L., C.A.L.-K., J.R.-M., G.J.B., V.F., J.J.B.); and Department of Hematopathology, Hospital Clinic, Barcelona, Spain (G.E.).
| |
Collapse
|
29
|
Agarwal N, Mahmoud AN, Patel NK, Jain A, Garg J, Mojadidi MK, Agrawal S, Qamar A, Golwala H, Gupta T, Bhatia N, Anderson RD, Bhatt DL. Meta-Analysis of Aspirin Versus Dual Antiplatelet Therapy Following Coronary Artery Bypass Grafting. Am J Cardiol 2018; 121:32-40. [PMID: 29122278 DOI: 10.1016/j.amjcard.2017.09.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 11/20/2022]
Abstract
Although aspirin monotherapy is considered the standard of care after coronary artery bypass grafting (CABG), more recent evidence has suggested a benefit with dual antiplatelet therapy (DAPT) after CABG. We performed a meta-analysis of observational studies and randomized controlled trials comparing outcomes of aspirin monotherapy with DAPT in patients after CABG. Subgroup analyses were conducted according to surgical technique (i.e., on vs off pump) and clinical presentation (acute coronary syndrome vs no acute coronary syndrome). Random effects overall risk ratios (RR) were calculated using the DerSimonian and Laird model. Eight randomized control trials and 9 observational studies with a total of 11,135 patients were included. At a mean follow-up of 23 months, major adverse cardiac events (10.3% vs 12.1%, RR 0.84, confidence interval [CI] 0.71 to 0.99), all-cause mortality (5.7% vs 7.0%, RR 0.67, CI 0.48 to 0.94), and graft occlusion (11.3% vs 14.2%, RR 0.79, CI 0.63 to 0.98) were less with DAPT than with aspirin monotherapy. There was no difference in myocardial infarction, stroke, or major bleeding between the 2 groups. In conclusion, DAPT appears to be associated with a reduction in graft occlusion, major adverse cardiac events, and all-cause mortality, without significantly increasing major bleeding compared with aspirin monotherapy in patients undergoing CABG.
Collapse
Affiliation(s)
- Nayan Agarwal
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Ahmed N Mahmoud
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Nimesh Kirit Patel
- Department of Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Ankur Jain
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Jalaj Garg
- Department of Medicine, Lehigh Valley, Allentown, Pennsylvania
| | | | - Sahil Agrawal
- Department of Medicine, St Lukes University Health Network, Bethlehem, Pennsylvania
| | - Arman Qamar
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Harsh Golwala
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tanush Gupta
- Department of Medicine, Montefiore Medical Centre, Albert Einstein College of Medicine, Bronx, New York
| | - Nirmanmoh Bhatia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - R David Anderson
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
| |
Collapse
|
30
|
Collet JP, Mair J, Plebani M, Merkely B, Jaffe AS, Möckel M, Giannitsis E, Thygesen K, ten Berg JM, Mueller C, Storey RF, Lindahl B, Huber K, Aradi D. Platelet function testing in acute cardiac care – is there a role for prediction or prevention of stent thrombosis and bleeding? Thromb Haemost 2017; 113:221-30. [DOI: 10.1160/th14-05-0449] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/05/2014] [Indexed: 01/02/2023]
Abstract
SummaryThe role of platelet function testing in acute coronary syndrome patients undergoing percutaneous coronary intervention remains controversial despite the fact that high platelet reactivity is an independent predictor of stent thrombosis and emerging evidence suggests also a link between low platelet reactivity and bleeding. In this expert opinion paper, the Study Group on Biomarkers in Cardiology of the Acute Cardiovascular Care Association and the Working Group on Thrombosis of the European Society of Cardiology aim to provide an overview of current evidence in this area and recommendations for practicing clinicians.
Collapse
|
31
|
Patrono C, Morais J, Baigent C, Collet JP, Fitzgerald D, Halvorsen S, Rocca B, Siegbahn A, Storey RF, Vilahur G. Antiplatelet Agents for the Treatment and Prevention of Coronary Atherothrombosis. J Am Coll Cardiol 2017; 70:1760-1776. [PMID: 28958334 DOI: 10.1016/j.jacc.2017.08.037] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 01/06/2023]
Abstract
Antiplatelet drugs provide first-line antithrombotic therapy for the management of acute ischemic syndromes (both coronary and cerebrovascular) and for the prevention of their recurrence. Their role in the primary prevention of atherothrombosis remains controversial because of the uncertain balance of the potential benefits and risks when combined with other preventive strategies. The aim of this consensus document is to review the evidence for the efficacy and safety of antiplatelet drugs, and to provide practicing cardiologists with an updated instrument to guide their choice of the most appropriate antiplatelet strategy for the individual patient presenting with different clinical manifestations of coronary atherothrombosis, in light of comorbidities and/or interventional procedures.
Collapse
Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
| | - Joao Morais
- Division of Cardiology, Santo Andre's Hospital, Leiria, Portugal
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jean-Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, and University of Oslo, Oslo, Norway
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
| |
Collapse
|
32
|
Cavalca V, Rocca B, Veglia F, Petrucci G, Porro B, Myasoedova V, De Cristofaro R, Turnu L, Bonomi A, Songia P, Cavallotti L, Zanobini M, Camera M, Alamanni F, Parolari A, Patrono C, Tremoli E. On-pump Cardiac Surgery Enhances Platelet Renewal and Impairs Aspirin Pharmacodynamics: Effects of Improved Dosing Regimens. Clin Pharmacol Ther 2017; 102:849-858. [DOI: 10.1002/cpt.702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- V Cavalca
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - B Rocca
- Department of Pharmacology; Catholic University; Rome Italy
| | - F Veglia
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - G Petrucci
- Department of Pharmacology; Catholic University; Rome Italy
| | - B Porro
- Monzino Cardiology Center, IRCCS; Milan Italy
| | | | | | - L Turnu
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - A Bonomi
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - P Songia
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | | | - M Zanobini
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - M Camera
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - F Alamanni
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - A Parolari
- Policlinico San Donato Hospital, IRCCS; San Donato Milanese Italy
| | - C Patrono
- Department of Pharmacology; Catholic University; Rome Italy
| | - E Tremoli
- Monzino Cardiology Center, IRCCS; Milan Italy
| |
Collapse
|
33
|
Dunne E, Egan K, McFadden S, Foley D, Kenny D. Platelet aggregation in response to ADP is highly variable in normal donors and patients on anti-platelet medication. Clin Chem Lab Med 2017; 54:1269-73. [PMID: 26562035 DOI: 10.1515/cclm-2015-0802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/07/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND P2Y12 inhibitors are indicated in patients following percutaneous coronary intervention. Several studies have demonstrated that high on treatment platelet reactivity is correlated with outcomes yet prospective studies of guided therapy have failed to show benefit. There is a paucity of studies on the platelet aggregation response to ADP before P2Y12 therapy is started. The aim of this study was to characterize platelet responses to 20 μM ADP by light transmission aggregometry (LTA) in a homogenous population. METHODS Platelet aggregation was assessed in 201 patients on dual antiplatelet therapy, 98 patients on aspirin alone and 47 normal, healthy volunteers free from anti-platelet medication. RESULTS Consensus guidelines suggest that a platelet aggregation response in response to the agonist ADP of <57% is an adequate therapeutic response to P2Y12 inhibition. Seven healthy donors and 38 patients taking aspirin only had aggregation responses below 57%. CONCLUSIONS The results of our study demonstrate that 15% of normal donors and 38% of patients taking aspirin only would be classified as having a therapeutic response to P2Y12 inhibition using current guidelines.
Collapse
|
34
|
Ahmadizad S, Nouri-Habashi A, Rahmani H, Maleki M, Naderi N, Lotfian S, Salimian M. Platelet activation and function in response to high intensity interval exercise and moderate continuous exercise in CABG and PCI patients. Clin Hemorheol Microcirc 2017; 64:911-919. [DOI: 10.3233/ch-168010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sajad Ahmadizad
- Department of Sport and Exercise Physiology, Faculty of Sports Sciences, Shahid Beheshti University, Tehran, Iran
| | - Akbar Nouri-Habashi
- Department of Sport and Exercise Physiology, Faculty of Sports Sciences, Shahid Beheshti University, Tehran, Iran
| | - Hiwa Rahmani
- Department of Sport and Exercise Physiology, Faculty of Sports Sciences, Shahid Beheshti University, Tehran, Iran
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Lotfian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Morteza Salimian
- Platelet Research Laboratory, Kashan University of Medical Sciences, Kashan, Iran
| |
Collapse
|
35
|
Bokeriya LA, Aronov DM. Russian clinical guidelines Coronary artery bypass grafting in patients with ischemic heart disease: rehabilitation and secondary prevention. ACTA ACUST UNITED AC 2016. [DOI: 10.26442/cs45210] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
36
|
Kayse R, Becker RC. The case for preoperative aspirin administration in patients undergoing elective CABG: is it open or closed? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S26. [PMID: 27867994 DOI: 10.21037/atm.2016.10.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Regina Kayse
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
37
|
Bonhomme F. Tests d’évaluation de la fonction plaquettaire délocalisés : un guide pour la transfusion de plaquettes ? Transfus Clin Biol 2016; 23:202-204. [DOI: 10.1016/j.tracli.2016.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
|
38
|
Keeling D, Tait RC, Watson H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016; 175:602-613. [DOI: 10.1111/bjh.14344] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/26/2016] [Accepted: 07/31/2016] [Indexed: 12/14/2022]
Affiliation(s)
- David Keeling
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | | | | | | |
Collapse
|
39
|
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.
Collapse
Affiliation(s)
- S Agarwal
- Department of Anaesthesia and Critical Care, Liverpool Heart and Chest Hospital, Liverpool, UK.
| |
Collapse
|
40
|
O'Connor SA, Amour J, Mercadier A, Martin R, Kerneis M, Abtan J, Brugier D, Silvain J, Barthélémy O, Leprince P, Montalescot G, Collet JP. Efficacy of ex vivo autologous and in vivo platelet transfusion in the reversal of P2Y12 inhibition by clopidogrel, prasugrel, and ticagrelor: the APTITUDE study. Circ Cardiovasc Interv 2016; 8:e002786. [PMID: 26553698 DOI: 10.1161/circinterventions.115.002786] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Allogenic platelet transfusions (PT) are administered to treat excessive bleeding in patients on P2Y12 receptor inhibitors (RI). We assessed the effect of ex vivo and in vivo PT on platelet activation and aggregation in patients on dual antiplatelet therapy. METHODS AND RESULTS In the Antagonize P2Y12 Treatment Inhibitors by Transfusion of Platelets in an Urgent or Delayed Timing After Acute Coronary Syndrome or Percutaneous Coronary Intervention Presentation-Acute Coronary Syndrome (APTITUDE-ACS) study, patients presenting with acute coronary syndrome or for elective percutaneous coronary intervention, receiving loading doses of clopidogrel (600 mg, n=13 or 900 mg, n=12), prasugrel 60 mg (n=10), or ticagrelor 180 mg (n=10) were included. PT was performed ex vivo by mixing platelet-rich plasma from blood sampling performed at baseline in increasing proportions with platelet-rich plasma sampled 4 hours after loading dose. The percentage restoration of residual platelet aggregation achieved with 80% proportion PT (residual platelet aggregation 80% PT mix/residual platelet aggregation baseline×100) significantly decreased with increasing potency of P2Y12 RI (83.9±11%, 73±14%, 66.3±15%, 40.9±19% for clopidogrel 600 mg, clopidogrel 900 mg, prasugrel, and ticagrelor, respectively; P for trend <0.0001). In the APTITUDE-Coronary Artery Bypass Graft (APTITUDE-CABG) study, vasodilator-stimulated phosphoprotein-platelet reactivity index, a specific marker of the P2Y12 RI drug-effect, was assessed before and after in vivo PT administered for excessive bleeding in patients undergoing cardiac surgery while on a maintenance dose of aspirin and clopidogrel (n=45), prasugrel (n=6), or ticagrelor (n=3). When compared with baseline, there was a significant relative increase of 23.1% in platelet activation after PT transfusion (42.2±23.6% versus 56.6±18.2%; P=0.0008). CONCLUSIONS PT restores platelet reactivity in patients with acute coronary syndrome/percutaneous coronary intervention and in patients undergoing cardiac surgery on P2Y12 RI while bleeding with a less effect with increasing potency of P2Y12 inhibition. CLINICAL TRIAL REGISTRATION URL: http://www.recherche-biomedicale.sante.gouv.fr/pro/comites/coordonnees.htm and http://www.cnil.fr/. Unique identifiers: No. 301111 and No. 1547216v0.
Collapse
Affiliation(s)
- Stephen A O'Connor
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Julien Amour
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Anne Mercadier
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Réjane Martin
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Mathieu Kerneis
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Jérémie Abtan
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Delphine Brugier
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Johanne Silvain
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Olivier Barthélémy
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Pascal Leprince
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Gilles Montalescot
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France.
| | - Jean-Philippe Collet
- From the Sorbonne Université UMPC (Paris 6), INSERM_UMRS1166 (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), ACTION Study Group, Paris, France (S.A.O., R.M., M.K., J.A., D.B., J.S., O.B., G.M., J.-P.C.), Département d'Anesthésie et de Réanimation (J.A., R.M.), Etablissement Français Sang (A.M.), and Institut de Cardiologie and Chirurgie Cardiaque (S.A.O., M.K., J.A., D.B., J.S., O.B., P.L., G.M., J.-P.C.), Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | | |
Collapse
|
41
|
Staudacher DL, Biever PM, Benk C, Ahrens I, Bode C, Wengenmayer T. Dual Antiplatelet Therapy (DAPT) versus No Antiplatelet Therapy and Incidence of Major Bleeding in Patients on Venoarterial Extracorporeal Membrane Oxygenation. PLoS One 2016; 11:e0159973. [PMID: 27467697 PMCID: PMC4965019 DOI: 10.1371/journal.pone.0159973] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/11/2016] [Indexed: 11/26/2022] Open
Abstract
Aims Bleeding is a frequent complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). An indication for dual antiplatelet therapy due to coronary stent implantation is present in a considerable number of these patients. The objective of this retrospective study was to evaluate if dual antiplatelet therapy (DAPT) significantly increases the high intrinsic bleeding risk in patients on VA-ECMO. Methods and Results A total of 93 patients were treated with VA-ECMO between October 2010 and October 2013. Average time on VA-ECMO was 58.9 ± 1.7 hours. Dual antiplatelet therapy was given to 51.6% of all patients. Any bleeding was recorded in 60.2% of all patients. There was no difference in bleeding incidence in patients on DAPT when compared to those without any antiplatelet therapy including any bleeding (66.7% vs. 57.1%, p = 0.35), BARC3 bleeding (43.8% vs. 33.3%, p = 0.31) or pulmonary bleeding (16.7% vs. 19.0%, p = 0.77). This holds true after adjustment for confounders. Rate of transfusion of red blood cells were similar in patients with or without DAPT (35.4% vs. 28.6%, p = 0.488). Conclusions Bleeding on VA-ECMO is frequent. This registry recorded no statistical difference in bleeding in patients on dual antiplatelet therapy when compared to no antiplatelet therapy. When indicated, DAPT should not be withheld from VA ECMO patients.
Collapse
Affiliation(s)
- Dawid L. Staudacher
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
- * E-mail:
| | - Paul M. Biever
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Christoph Benk
- Heart Center Freiburg University, Department of Cardiovascular Surgery, Freiburg, Germany
| | - Ingo Ahrens
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Christoph Bode
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| | - Tobias Wengenmayer
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Freiburg, Germany
| |
Collapse
|
42
|
Baryshnikova E, Ranucci M. Point-of-care haemostasis and coagulation monitoring in cardiac surgery at IRCCS Policlinico San Donato. Eur Heart J Suppl 2016; 18:E42-E48. [PMID: 28533716 DOI: 10.1093/eurheartj/suw013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A rational management of perioperative and postoperative bleeding in modern cardiac surgery requires a thorough application of point-of-care (POC) monitoring in order to prevent and readily treat alterations of the haemostatic process. Preoperative platelet dysfunction, residual heparin after extracorporeal circulation, coagulation factors, and/or fibrinogen deficiency could be ruled out and specifically addressed with an appropriate treatment. Our approach includes preoperative platelet function testing of patients administered with thienopyridines or ticagrelor within 7-10 days before planned surgery and platelet function testing-based surgery timing. In the case of postoperative bleeding, residual heparin is tested and additional protamine is eventually administered. Simultaneously, an overall activity of coagulation factors (except fibrinogen) is assessed and, if significantly reduced, correction with prothrombotic complex concentrate is considered. If fibrinogen deficiency is suspected, a specific test is run, and in the case of severe reduction, the deficiency is compensated by fibrinogen concentrate or appropriate volume of fresh-frozen plasma. If both coagulation factors and fibrinogen activity are reduced, fibrinogen is usually considered for correction as first line, followed by prothrombin complex concentrate in the case of further bleeding. It is our clinical practice not to test nor to treat patients until postoperative bleeding appears clinically relevant. At IRCCS Policlinico San Donato, we firmly believe in the importance of the POC-based strategy for haemostatic treatment and constantly update our knowledge through research projects targeted in answering clinically relevant questions.
Collapse
Affiliation(s)
- Ekaterina Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| |
Collapse
|
43
|
Engert A, Balduini C, Brand A, Coiffier B, Cordonnier C, Döhner H, de Wit TD, Eichinger S, Fibbe W, Green T, de Haas F, Iolascon A, Jaffredo T, Rodeghiero F, Salles G, Schuringa JJ. The European Hematology Association Roadmap for European Hematology Research: a consensus document. Haematologica 2016; 101:115-208. [PMID: 26819058 PMCID: PMC4938336 DOI: 10.3324/haematol.2015.136739] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/27/2016] [Indexed: 01/28/2023] Open
Abstract
The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.
Collapse
Affiliation(s)
| | | | - Anneke Brand
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | | | | | | | | | | | - Willem Fibbe
- Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Tony Green
- Cambridge Institute for Medical Research, United Kingdom
| | - Fleur de Haas
- European Hematology Association, The Hague, the Netherlands
| | | | | | | | - Gilles Salles
- Hospices Civils de Lyon/Université de Lyon, Pierre-Bénite, France
| | | |
Collapse
|
44
|
The art of saphenous vein grafting and patency maintenance. J Thorac Cardiovasc Surg 2016; 151:300-2. [DOI: 10.1016/j.jtcvs.2015.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 11/17/2022]
|
45
|
Impact of prasugrel pretreatment and timing of coronary artery bypass grafting on clinical outcomes of patients with non-ST-segment elevation myocardial infarction: From the A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST-Elevation Myocardial Infarction (ACCOAST) study. Am Heart J 2015; 170:1025-1032.e2. [PMID: 26542513 DOI: 10.1016/j.ahj.2015.07.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/16/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We evaluated impact of timing of coronary artery bypass grafting (CABG) and prasugrel pretreatment in patients with non-ST-segment elevation myocardial infarction undergoing CABG in the ACCOAST study. METHODS Of 4033 enrolled patients, 314 (7.8%) underwent isolated CABG through 30 days. Primary efficacy end point for this analysis was any cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout through 30 days. RESULTS More CABG versus percutaneous coronary intervention or medically managed patients were men, diabetic, or had peripheral arterial disease. Per randomization, 157 of 314 patients received a 30-mg prasugrel loading dose before CABG, and 157 of 314 received placebo. Patients were stratified by tertile of time from randomization to CABG: <2.98 days (n = 104), ≥2.98 and <6.95 days (n = 106), and ≥6.95 days (n = 104). Primary end point occurred in 12.5%, 4.7%, and 4.8%, respectively (<2.98 days vs other tertiles, hazard ratio [HR] = 2.80; P = .011). Similarly, the rate of all TIMI major bleeding was highest in the lowest tertile (26.0% vs 10.4% and 4.8%; P < .001), but no difference in all-cause death was observed through 30 days (3.9% vs 1.9% and 1.9%; P = .30). Time from randomization to CABG (HR = 0.84 for each day delay), left main disease (HR = 1.76), region of enrollment (Non-Eastern Europe vs Eastern Europe; HR = 3.83), but not prasugrel pretreatment and baseline troponin ≥3× upper limit of normal, were independent predictors of combined 30-day end point of all-cause death/myocardial infarction/stroke/TIMI major bleeding. CONCLUSIONS In ACCOAST, early (<2.98 days) surgical revascularization carried increased risk of bleeding and ischemic complications without affecting all-cause mortality through 30 days. Baseline troponin and prasugrel pretreatment did not impact ischemic clinical outcomes.
Collapse
|
46
|
Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Surgical Revascularization versus Percutaneous Coronary Intervention and Optimal Medical Therapy in Diabetic Patients with Multi-Vessel Coronary Artery Disease. Prog Cardiovasc Dis 2015; 58:306-15. [PMID: 26255239 DOI: 10.1016/j.pcad.2015.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Coronary artery disease (CAD) is the leading cause of death in patients with diabetes mellitus (DM). Patients with DM and CAD undergoing revascularization with either a surgical or a percutaneous approach are at higher risk of adverse outcomes and mortality compared with non-DM patients. It is within this background that the optimal choice of revascularization is of critical importance in this high-risk population. The large FREEDOM trial randomized 1900 patients with DM and multivessel CAD to either revascularization with coronary artery by-pass graft (CABG) surgery or percutaneous coronary intervention (PCI). Compared with PCI, CABG significantly reduced the rates of death and myocardial infarction but was associated with a higher risk of stroke. In a real-world setting the decision-making process for the optimal revascularization strategy in these patients is challenging as many clinical factors may influence the decision to either pursue a surgical or a percutaneous revascularization. However, the current consensus is that CABG should be the preferred revascularization strategy in diabetic patients with extensive multivessel CAD.
Collapse
|
48
|
Harding SA, Van Gaal WJ, Schrale R, Gunasekara A, Amerena J, Mussap CJ, Aylward PE. Practical experience with ticagrelor: an Australian and New Zealand perspective. Curr Med Res Opin 2015; 31:1469-77. [PMID: 26086451 DOI: 10.1185/03007995.2015.1058247] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Ticagrelor is recommended in local and international guidelines as first-line therapy in combination with aspirin in patients presenting with acute coronary syndromes (ACS). The purpose of this article is to provide practical guidance regarding the use of ticagrelor in this setting. METHODS AND RESULTS Ticagrelor, a direct-acting, reversible P2Y12 receptor antagonist, has a faster onset, and a more potent and predictable antiplatelet effect compared with clopidogrel. The authors recommend considering the use of ticagrelor in moderate-to-high risk ACS patients treated with an invasive approach and those managed non-invasively who have elevated troponin levels. Consistent with outcomes observed in the PLATO trial overall, ticagrelor was superior to clopidogrel treatment in patients with chronic kidney disease, a history of stroke or transient ischemic attack, the elderly, and patients requiring surgical revascularization. CONCLUSIONS When switching from clopidogrel to ticagrelor, patients established on clopidogrel therapy can be switched directly without loading; patients not loaded with clopidogrel and not taking maintenance dose clopidogrel for at least 5 days should first be loaded with ticagrelor. Guidelines recommend discontinuing ticagrelor 5 days before surgery if antiplatelet effects are not desired and recommencing therapy as soon as safe following surgery. Ticagrelor should be avoided in individuals with a history of intracranial hemorrhage, moderate-to-severe hepatic impairment, high bleeding risk, within 24 hours of thrombolytic therapy, and in those treated with oral anticoagulants. Local, real-world experience suggests low bleeding rates with ticagrelor therapy. Dyspnoea is a common symptom in patients with ACS and is also a side-effect of ticagrelor therapy. Discontinuation of ticagrelor due to dyspnoea has been uncommon in clinical trials. However, local registry data suggest higher discontinuation rates (2-9%) related to dyspnoea in the real-world setting, indicating that clinicians may need to consider other potential causes of dyspnoea before discontinuing ticagrelor.
Collapse
|
49
|
Andreotti F, Rocca B, Husted S, Ajjan RA, ten Berg J, Cattaneo M, Collet JP, De Caterina R, Fox KAA, Halvorsen S, Huber K, Hylek EM, Lip GYH, Montalescot G, Morais J, Patrono C, Verheugt FWA, Wallentin L, Weiss TW, Storey RF. Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2015; 36:3238-49. [PMID: 26163482 DOI: 10.1093/eurheartj/ehv304] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 06/12/2015] [Indexed: 12/19/2022] Open
Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Science, Catholic University Medical School, Largo F Vito 1, Rome 00168, Italy
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Steen Husted
- Medical Department, Region Hospital West, Herning/Holstebro, Denmark
| | - Ramzi A Ajjan
- Division of Cardiovascular and Diabetes Research, The LIGHT Laboratories, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, UK
| | - Jurrien ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco Cattaneo
- Medicina 3, Ospedale San Paolo - Dipartimento di SCienze della Salute, UNiversità degli Studi di Milano, Milan, Italy
| | - Jean-Philippe Collet
- Institut de Cardiologie, INSERM UMRS 1166, Allies in Cardiovascular Trials Initiatives and Organized Networks Group, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Université Pierre et Marie Curie, Paris, France
| | - Raffaele De Caterina
- Department of Cardiology, 'G. d'Annunzio' University - Ospedale SS. Annunziata, Chieti, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Sigrun Halvorsen
- Department of Cardiology B, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna A-1160, Austria
| | - Elaine M Hylek
- Department of Medicine, Boston University School of Medicine-Boston Medical Center, Boston, MA, USA
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Gilles Montalescot
- Institut de Cardiologie, INSERM UMRS 1166, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Université Pierre et Marie Curie, Paris, France
| | - Joao Morais
- Department of Cardiology, Hospital de Santo André, Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | | | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences (Cardiology), Uppsala University, Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Internal Medicine, Cardiology and Emergency Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna A-1160, Austria
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | | |
Collapse
|
50
|
Bomb R, Oliphant CS, Khouzam RN. Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting in the Setting of Acute Coronary Syndrome. Am J Cardiol 2015; 116:148-54. [PMID: 25933730 DOI: 10.1016/j.amjcard.2015.03.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 03/26/2015] [Accepted: 03/26/2015] [Indexed: 01/28/2023]
Abstract
After acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) is the standard of care for both invasive management with percutaneous intervention and noninvasive (medical) management. Conversely, studies using dual antiplatelet in the population of patients presenting with ACS who undergo coronary artery bypass grafting (CABG) are conflicting. The appropriate antiplatelet regimen after CABG remains an area of controversy. Plaque stability, prevention of graft closure, and secondary thrombosis form the basis for using a second antiplatelet drug, whereas the additional risk of bleeding and lack of conclusive evidence should also be considered. After an extensive literature search, 12 clinical trials with efficacy outcomes were identified. Most of the studies are retrospective, nonrandomized single-center trials. A few large patient populations have been examined using database information. To date, there is only 1 prospective, multicenter, randomized trial published. Recommendations from national guidelines differ, proposing single antiplatelet therapy with aspirin or DAPT with the combination of aspirin and clopidogrel. The purpose of this report is to review the available clinical trial data and provide guidance to practitioners when caring for this patient population. In conclusion, there is no clear consensus regarding the use of DAPT in patients after CABG. If not contraindicated, it is reasonable to use DAPT, starting in the postoperative period, in patients presenting with ACS. Large, multicenter, randomized clinical trials are needed to definitively investigate the role of DAPT in patients with ACS after CABG.
Collapse
Affiliation(s)
- Ritin Bomb
- Division of Cardiovascular diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Carrie S Oliphant
- Department of Pharmacy, Methodist University Hospital, Memphis, TN; Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, TN
| | - Rami N Khouzam
- Division of Cardiovascular diseases, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.
| |
Collapse
|