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Thet MS, Khosravi A, Egbulonu S, Oo AY. Antiplatelet Resistance in Coronary Artery Bypass Grafting: A Systematic Review. Surg Res Pract 2024; 2024:1807241. [PMID: 38910604 PMCID: PMC11193597 DOI: 10.1155/2024/1807241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/26/2024] [Accepted: 06/08/2024] [Indexed: 06/25/2024] Open
Abstract
Background This systematic review examines the occurrence and implications of resistance to primary antiplatelet agents, aspirin and clopidogrel, often utilised in patients undergoing coronary artery bypass grafting (CABG), alongside the methodologies for assessment of such resistance. Methods An extensive literature search across various databases such as PubMed, MEDLINE via Ovid, Embase, and Cochrane CENTRAL until May 2024 was conducted to identify studies evaluating antiplatelet resistance in on-pump and off-pump CABG patients. Following quality assessment, only high-quality studies were incorporated into this review. Results This review included 19 studies with 3,915 patients, four of which were randomised controlled trials and 15 were observational studies. Aspirin resistance incidence ranged from 11.0% to 51.5%, while clopidogrel resistance was 22%. Antiplatelet resistance, assessed through a wide variety of methods, was associated with a 13 times increase in the risk of vein graft occlusion and increased rates of mortality, myocardial infarction, and target vessel revascularisation in the case of clopidogrel resistance. The effect of cardiopulmonary bypass on antiplatelet resistance remains ambiguous. Conclusion The academic literature lacks a standardised definition for antiplatelet resistance. Assessment methodologies greatly vary, leading to noninterchangeable outcomes. While aspirin resistance has a conflicting overall significant impact on adverse outcomes, clopidogrel resistance correlates with poorer clinical outcomes.
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Affiliation(s)
- Myat Soe Thet
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Amir Khosravi
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Samson Egbulonu
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
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Hasan SU, Pervez A, Shah AA, Shah SDA, Aslam M, Arshad A, Rajput AS, Zubair MM. Safety outcomes of anti-platelet therapy post coronary artery bypass graft surgery: A systematic review and network meta-analysis of randomized control trials. Perfusion 2024; 39:684-697. [PMID: 36803180 DOI: 10.1177/02676591231159513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Antiplatelet therapy is used to decrease the risk of graft failure post coronary artery bypass graft surgery. We aimed to compare dual antiplatelet therapy (DAPT) with monotherapy along with a comparison of Aspirin, Ticagrelor, Aspirin+Ticagrelor (A+T) and Aspirin+Clopidogrel (A+C) to determine the major and minor bleeding risk, risk of postoperative myocardial infarction (MI), stroke, and all-cause mortality (ACM). METHODS Randomized Controlled Trials comparing the four groups were included. Odds ratio (OR) and Absolute Risk (AR) were employed to assess the mean and standard deviation (SD) with 95% confidence intervals (CI). The Bayesian random-effects model was used for statistical analysis. Risk difference and Cochran Q tests were used to calculate rank probability (RP) and heterogeneity, respectively. RESULTS We included 10 trials, consisting of 21 arms and 3926 patients. For the risk of major and minor bleed, A + T and Ticagrelor showed the lowest mean value of 0.040 (0.043) and 0.067 (0.073), respectively, and the highest RP of being the safest group. While a direct comparison between DAPT and monotherapy resulted in an OR of 0.57 [0.34, 0.95] for the risk of minor bleed. A + T was found to have the highest RP and the lowest mean value in terms of ACM, MI, and stroke. CONCLUSION No significant difference was found between monotherapy or dual-antiplatelet therapy for the major bleeding risk safety outcome, however DAPT was found to have a significantly higher rate of minor bleeding complications post-CABG. DAPT should be considered as the antiplatelet modality of choice post-CABG.
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Affiliation(s)
| | | | - Arshad A Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Syed DA Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Aslam
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Anosha Arshad
- Dow University of Health Sciences, Karachi, Pakistan
| | - Amna S Rajput
- Dow University of Health Sciences, Karachi, Pakistan
| | - M Mujeeb Zubair
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: the latest evidence. Curr Opin Cardiol 2023; 38:484-489. [PMID: 37751394 PMCID: PMC10552805 DOI: 10.1097/hco.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The optimal antiplatelet strategy in patients after coronary artery bypass graft (CABG) surgery is unclear. We review the evidence on the efficacy and safety of DAPT after CABG and discuss potential novel antiplatelet strategies that reduce the risk of bleeding without loss of efficacy. RECENT FINDINGS Adding the potent P2Y12 inhibitor ticagrelor to aspirin for 1 year after CABG is associated with a reduction in the risk of vein graft failure, at the expense of an increased risk of clinically important bleeding. Ticagrelor monotherapy is not associated with better efficacy than aspirin alone, but is not associated with increased bleeding risk. SUMMARY Dual antiplatelet therapy (DAPT) is recommended after acute coronary syndrome events, but aspirin as single antiplatelet therapy remains the cornerstone of antithrombotic therapy in stable ischemic heart disease because of a lack of solid evidence on the benefit of DAPT on clinical outcomes. Shorter duration DAPT, based on the pathophysiology of vein graft failure, may be a promising strategy that requires testing in adequately powered randomized trials.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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Malm CJ, Alfredsson J, Erlinge D, Gudbjartsson T, Gunn J, James S, Møller CH, Nielsen SJ, Sartipy U, Tønnessen T, Jeppsson A. Dual or single antiplatelet therapy after coronary surgery for acute coronary syndrome (TACSI trial): Rationale and design of an investigator-initiated, prospective, multinational, registry-based randomized clinical trial. Am Heart J 2023; 259:1-8. [PMID: 36681173 DOI: 10.1016/j.ahj.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 05/11/2023]
Abstract
The TACSI trial (ClinicalTrials.gov Identifier: NCT03560310) tests the hypothesis that 1-year treatment with dual antiplatelet therapy with acetylsalicylic acid (ASA) and ticagrelor is superior to only ASA after isolated coronary artery bypass grafting (CABG) in patients with acute coronary syndrome. The TACSI trial is an investigator-initiated pragmatic, prospective, multinational, multicenter, open-label, registry-based randomized trial with 1:1 randomization to dual antiplatelet therapy with ASA and ticagrelor or ASA only, in patients undergoing first isolated CABG, with a planned enrollment of 2200 patients at Nordic cardiac surgery centers. The primary efficacy end point is a composite of time to all-cause death, myocardial infarction, stroke, or new coronary revascularization within 12 months after randomization. The primary safety end point is time to hospitalization due to major bleeding. Secondary efficacy end points include time to the individual components of the primary end point, cardiovascular death, and rehospitalization due to cardiovascular causes. High-quality health care registries are used to assess primary and secondary end points. The patients will be followed for 10 years. The TACSI trial will give important information useful for guiding the antiplatelet strategy in acute coronary syndrome patients treated with CABG.
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Affiliation(s)
- Carl Johan Malm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Christian H Møller
- Department for Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Theis Tønnessen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Norway; University of Oslo, Oslo, Norway
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Balaj I, Jakob H, Haddad A, Mourad F, Haneya A, Ali E, Ryadi N, Thielmann M, Ruhparwar A, Shehada SE. Role of Antiplatelet Therapy in Patients with Severe Coronary Artery Disease Undergoing Coronary Artery Endarterectomy within Coronary Artery Bypass Surgery. J Cardiovasc Dev Dis 2023; 10:jcdd10030112. [PMID: 36975876 PMCID: PMC10051999 DOI: 10.3390/jcdd10030112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/19/2023] [Accepted: 03/01/2023] [Indexed: 03/10/2023] Open
Abstract
Background—Coronary endarterectomy (CEA) has been introduced to allow revascularization in end-stage coronary artery disease (CAD). After CEA, the injured remnants of the vessel’s media could result in fast neo intimal tissue ingrowth, which require an anti-proliferation agent (antiplatelet therapy (APT). We aimed to review outcomes of patients undergoing CEA within bypass surgery who received either single-APT (SAPT) or dual-APT (DAPT). Methods—We retrospectively evaluated 353 consecutive patients undergoing CEA within isolated coronary artery bypass grafting (CABG) in the period 01/2000–07/2019. After surgery, patients received either SAPT (n = 153), or DAPT (n = 200) for six months then lifelong SAPT. Endpoints included early, late survival, and freedom from major-adverse-cardiac and cerebrovascular events (MACCE), which were defined as incidence of stroke, myocardial infarction, need for coronary intervention (PCI or CABG) or death for any cause. Results—Patients’ mean age was 67 ± 9.3 years; they were predominantly male 88.1%. Both DAPT- and SAPT-groups had the same extent of CAD (mean SYNTAX-Score-II: 34.1 ± 11.6 vs. 34.4 ± 17.2, p = 0.91). Postoperatively, no difference between DAPT- and SAPT-groups was reported in the incidence of low-cardiac-output syndrome (5% vs. 9.8%, p = 0.16), revision for bleeding (5% vs. 6.5% p = 0.64), 30-day mortality (4.5% vs. 5.2%, p = 0.8) or MACCE (7.5% vs. 11.8%, p = 0.19). Imaging follow-up reported significantly higher CEA and total grafts patency (90% vs. 81.5% and 95% vs. 81%, p = 0.017) in DAPT patients. Late outcomes within 97.4 ± 67.4 months show lower incidence of overall mortality (19 vs. 51%, p < 0.001) and MACCE (24.5 vs. 58.2%, p < 0.001) in the DAPT patients when compared with SAPT patients. Conclusions—Coronary endarterectomy allows revascularization in end-stage CAD when the myocardium is still viable. The use of dual APT after CEA for at least six months seems to improve mid-to-long-term patency rates and survival, and reduced the incidence of major adverse cardiac and cerebrovascular events.
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Affiliation(s)
- Ilir Balaj
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Ali Haddad
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Fanar Mourad
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Assad Haneya
- Department of Cardiac and Vascular Surgery, Campus Kiel, University-Medical-Center Schleswig-Holstein, 24106 Kiel, Germany
| | - Ebrahim Ali
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Noura Ryadi
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany
- Correspondence:
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7
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Kaveshnikov VS, Kuzmichkina MA, Serebryakova VN. Predictors of Long-Term Outcomes after Surgical Myocardial Revascularization. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2022-12-09] [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
High mortality from cardiovascular diseases (CVD) requires improved approaches to the treatment of this socially significant pathology. Wide implementation of surgical myocardial revascularization makes it possible to improve significantly both life quality and expectancy in patients with coronary heart disease. The aim of this work was to analyze the literature on the impact of preoperative, operative and postoperative factors on the long-term prognosis after coronary artery bypass grafting (CABG). The review refers to both recent and earlier informative works. The target groups for this article are therapists, cardiologists, rehabilitologists, who work with patients in the short and long term after CABG. Data of Russian and foreign literature show that the long-term prognosis after CABG is largely determined by preoperative factors, in particular – age, set of cardiovascular risk factors (RF) and comorbidity, specifically – severity of coronary and systemic atherosclerosis, incident cardiovascular complications, structural and functional state of the heart. In the aggregate these factors reflect the cumulative effect and further potential of actual cardiovascular RFs, affect longterm risk of adverse events, and determine the therapeutic targets of secondary prevention. Priority of arterial conduits and completeness of revascularization are the main operative factors that determine the course of the long-term period after CABG. Among the postoperative factors, the efficiency of secondary CVD prevention is of paramount importance, in particular – achievement of target RF levels, compensation of cardiac and extracardiac pathology, adherence to the long-term medical therapy, known to improve outcomes based on specific comorbidity. Efficiency of secondary CVD prevention largely depends on patient's health attitudes, the key influence on which beyond attending physician can be provided by participation in rehabilitation programs, teaching patients the meaning and essentials of lifestyle modification and cardiovascular RFs’ control.
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Affiliation(s)
- V. S. Kaveshnikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - M. A. Kuzmichkina
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - V. N. Serebryakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
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8
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Brieger D, Chew D, Goodman S, Hammett C, Lefkovits J, Farouque O, Atherton J, Hyun K, D'Souza M. Balancing the Risks of Recurrent Ischaemic and Bleeding Events in a Stable Post ACS Population. Heart Lung Circ 2022; 31:1349-1359. [PMID: 35863981 DOI: 10.1016/j.hlc.2022.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/31/2022] [Accepted: 05/20/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To better guide decisions regarding antithrombotic treatment in individual patients surviving 6 months following an acute coronary syndrome (ACS) by balancing between subsequent recurrent ischaemic and bleeding risk. METHODS Patients surviving 6 months following an ACS were followed in an Australian registry. Ischaemic (composite of cardiovascular death, myocardial infarction or stroke) and bleeding (≥BARC 2) events were collected. A dual binary outcome modelling strategy was used arriving at a common set of variables from which bleeding and ischaemic risk could be independently determined in individual patients. Patients in whom bleeding rates exceeded composite ischaemic event rates during the follow-up period were identified. RESULTS The cohort comprised 5,905 patients in whom 215 experienced an ischaemic event and 49 a bleeding event. The single set of variables included in both ischaemic and bleeding models (C-statistics 0.71 and 0.72 respectively) included modified TIGRIS1 ischaemic score, mode of revascularisation, history of heart failure, anaemia, multivessel disease, readmission within 6 months of index ACS and age >75. In the majority, ischaemic events were more frequent than bleeding events. In higher risk patients post coronary artery bypass grafting (CABG), bleeding events were more frequent than recurrent ischaemic events. CONCLUSION The risk of recurrent ischaemic events exceeds bleeding in most patients followed 6 to 24 months following an ACS. Post CABG patients with comorbidities have a higher risk of bleeding over this period during which time attention should be directed towards modifiable bleeding risk factors including requirement for dual antiplatelet therapy.
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Affiliation(s)
- David Brieger
- Concord Hospital, and ANZAC Institute University of Sydney, Sydney, NSW, Australia.
| | - Derek Chew
- Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | | | | | - John Atherton
- Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Karice Hyun
- Concord Hospital, and ANZAC Institute University of Sydney, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mario D'Souza
- Concord Hospital, and ANZAC Institute University of Sydney, Sydney, NSW, Australia
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9
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Sadeghi R, Haji Aghajani M, Miri R, Kachoueian N, Jadbabaei AN, Mahjoob MP, Omidi F, Ghazanfarabadi M, Sarveazad A. Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study. BMC Surg 2021; 21:449. [PMID: 34972501 PMCID: PMC8720217 DOI: 10.1186/s12893-021-01436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. METHODS In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. RESULTS The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9-20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). CONCLUSIONS A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.
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Affiliation(s)
- Roxana Sadeghi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Miri
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naser Kachoueian
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Nasser Jadbabaei
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Parsa Mahjoob
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Omidi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Ghazanfarabadi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.
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10
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Tzoumas A, Nagraj S, Tasoudis P, Arfaras-Melainis A, Palaiodimos L, Kokkinidis DG, Kampaktsis PN. Atrial fibrillation following coronary artery bypass graft: Where do we stand? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:172-179. [PMID: 34949543 DOI: 10.1016/j.carrev.2021.12.006] [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: 11/01/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 01/29/2023]
Abstract
Atrial fibrillation (AF) is the most common atrial arrhythmia following coronary artery bypass graft (CABG). Its prevalence is 15-45% and is associated with poor long-term prognosis. Risk factors can be patient-related, intraoperative, and/or postoperative. Therapeutic and preventive strategies have been developed to curtail AF burden. Cardioversion is recommended for unstable or symptomatic patients and rate control if asymptomatic. Anticoagulation is challenging with risk of thromboembolism and bleeding. However, patients should be anticoagulated after cardioversion or if AF persists >48 h and risk factors of stroke exist. A minimum of 4 weeks is recommended but longer duration should be considered in patients at high risk of stroke irrespective of recurrence of AF.
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Affiliation(s)
- Andreas Tzoumas
- Aristotle University of Thessaloniki, Thessaloniki 541 24, Greece
| | - Sanjana Nagraj
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA..
| | | | - Angelos Arfaras-Melainis
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA
| | - Leonidas Palaiodimos
- Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham parkway S, The Bronx, NY, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, 333 Cedar St, New Haven, CT, USA
| | - Polydoros N Kampaktsis
- Division of Cardiology, New York University Langone Medical Center, 550 1st Ave, New York, NY, USA
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11
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Abbasciano RG, Gradinariu G, Kourliouros A, Lai F, Langrish J, Murphy G, Quarto C, Radhakrishnan A, Raja S, Rogers LJ, Townend J, Tyson N, Vaja R, Verdichizzo D, Wynne R. Antithrombotic treatment following coronary artery bypass surgery: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - George Gradinariu
- Department of Cardiothoracic Surgery; Golden Jubilee National Hospital; Glasgow UK
| | - Antonios Kourliouros
- Oxford Heart Centre; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Florence Lai
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - Jeremy Langrish
- Oxford Heart Centre; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Gavin Murphy
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - Cesare Quarto
- Department of Cardiac Surgery; Royal Brompton and Harefield Hospital; London UK
| | | | - Shahzad Raja
- Department of Cardiac Surgery; Royal Brompton and Harefield Hospital; London UK
| | - Luke J Rogers
- Bristol Heart Institute; University Hospitals Bristol and Weston NHS Foundation Trust; Bristol UK
| | - Jonathan Townend
- Department of Cardiology; Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust; Birmingham UK
| | - Nathan Tyson
- Trent Cardiac Centre; Nottingham University Hospitals NHS Trust; Nottingham UK
| | - Ricky Vaja
- Department of Cardiac Surgery; Royal Brompton and Harefield Hospital; London UK
| | - Danilo Verdichizzo
- Oxford Heart Centre; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Rochelle Wynne
- Western Sydney Nursing & Midwifery Research Centre; Western Sydney University; Sydney Australia
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12
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Rubboli A, Vecchio S. Antiplatelet therapy after coronary bypass grafting: which regimen and for whom? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:527-528. [PMID: 33075120 DOI: 10.1093/ehjcvp/pvaa091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, Ravenna, 48121, Italy
| | - Sabine Vecchio
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, Ravenna, 48121, Italy
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13
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Roberto M, Radovanovic D, Buttà C, Tersalvi G, Krüll J, Erne P, Rickli H, Pedrazzini GB, Moccetti M. Dual antiplatelet therapy is under-prescribed in patients with surgically treated acute myocardial infarction. Interact Cardiovasc Thorac Surg 2021; 33:687-694. [PMID: 34171919 PMCID: PMC8691680 DOI: 10.1093/icvts/ivab159] [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: 01/24/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Despite guideline recommendations, previous reports, coming mainly from outside Europe, showed low rates of prescriptions for dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI) undergoing surgical revascularization. The present study assesses this issue in the era of potent P2Y12 inhibitors in Switzerland. METHODS All patients with a diagnosis of AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry from January 2014 to December 2019 were screened; 9050 patients undergoing either percutaneous (8727, 96.5%) or surgical (323, 3.5%) revascularization were included in the analysis. RESULTS Surgically treated patients were significantly less likely to receive DAPT at discharge (56.3% vs 96.7%; P < 0.001). Even when discharged with a prescription for DAPT, those patients were significantly less likely to receive a regimen containing a new P2Y12 inhibitor (67/182 [36.8%] vs 6945/8440 [83.2%]; P < 0.001). At multivariate analysis, surgical revascularization was independently associated with a lower likelihood of receiving a prescription for DAPT at discharge (odds ratio 0.03, 95% confidence interval 0.02-0.06). CONCLUSIONS DAPT prescriptions for patients with AMI undergoing surgical revascularization are not in line with current guideline recommendations. Efforts are necessary to clarify the role of DAPT for secondary prevention in these patients and increase the confidence of treating physicians in guideline recommendations. CLINICAL TRIAL REGISTRATION Acute Myocardial Infarction in Switzerland Plus Registry; registration number at ClinicalTrials.gov: NCT01305785.
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Affiliation(s)
- Marco Roberto
- Cardiology Department, Cardiocentro Ticino, Lugano, Switzerland
| | - Dragana Radovanovic
- AMIS Plus Data Centre, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Carmelo Buttà
- Cardiology Department, Cardiocentro Ticino, Lugano, Switzerland
- Unità Operativa Complessa di Cardiologia, Barone Romeo Hospital, Patti, Italy
| | - Gregorio Tersalvi
- Cardiology Department, Cardiocentro Ticino, Lugano, Switzerland
- Internal Medicine Department, Hirslanden Klinik St. Anna, Luzern, Switzerland
| | - Joël Krüll
- Cardiology Department, Cardiocentro Ticino, Lugano, Switzerland
| | - Paul Erne
- AMIS Plus Data Centre, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Hans Rickli
- Cardiology Department, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Marco Moccetti
- Cardiology Department, Cardiocentro Ticino, Lugano, Switzerland
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14
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Bayam E, Öztürkeri B, Yıldırım E, Kalçık M, Küp A, Çakmak EÖ, Günay N, Güner A, Kalkan S, Karaduman A, Kahyaoğlu M, Zehir R. The relationship between dual antiplatelet treatment (DAPT) score and saphenous venous grafts patency after coronary artery bypass grafting surgery. Acta Cardiol 2021; 76:785-791. [PMID: 33880976 DOI: 10.1080/00015385.2021.1912248] [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] [Indexed: 12/27/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) remains the gold standard treatment for mutivessel and left main coronary artery disease (CAD). Saphenous vein graft (SVG) patency is still a problem in CAD patients after CABG surgery. The Dual Antiplatelet Treatment (DAPT) score is a clinical prediction tool that predicts ischaemic and bleeding risk in CAD patients. The aim of this study is to investigate the relationship between DAPT score and SVG patency in CABG patients. METHOD This retrospective study enrolled a total of 398 patients (68 female; mean age 65.8 ± 9.1 years) with a history of CABG surgery. The study population was divided into two subgroups according to SVG patency. The DAPT score was calculated for each patients and compared between the two groups. RESULTS Coronary angiography revealed SVG disease in 212 patients and SVG patency in 186 patients. The rates of diabetes mellitus and hypertension, red cell distribution width values, DAPT Score, time interval after CABG and number of SVGs were significantly higher while LVEF was significantly lower in patients with SVG disease. The presence of diabetes mellitus, high DAPT score, long time interval after CABG and high number of SVGs were found to be independent predictors of SVG patency. DAPT score above 2.5 predicted SVG disease with a sensitivity of 77.1% and a specificity of 87.1% (AUC: 0.873; 95%CI: 0.823-0.924; p < 0.001). CONCLUSION The DAPT score may provide useful information for SVG patency in CABG patients. Patients with high DAPT score should be followed up closely for SGV occlusion. DAPT score may be useful prior to CABG in determining the duration of dual anti-platelet therapy and in encouraging the use of arterial grafts with better patency.
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Affiliation(s)
- Emrah Bayam
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Burak Öztürkeri
- Depertament of Cardiology, Umraniye Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Ersin Yıldırım
- Depertament of Cardiology, Umraniye Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Macit Kalçık
- Depertament of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Ayhan Küp
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Ender Özgün Çakmak
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Nuran Günay
- Depertament of Cardiology, Umraniye Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Semih Kalkan
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | - Ahmet Karaduman
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
| | | | - Regayip Zehir
- Depertament of Cardiology, Kartal Kosuyolu High Specialty Training and Research Hospital, University of Medical Sciences, İstanbul, Turkey
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15
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Björklund E, Malm CJ, Nielsen SJ, Hansson EC, Tygesen H, Romlin BS, Martinsson A, Omerovic E, Pivodic A, Jeppsson A. Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome. JAMA Netw Open 2021; 4:e2122597. [PMID: 34436610 PMCID: PMC8391102 DOI: 10.1001/jamanetworkopen.2021.22597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak. OBJECTIVE To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy. DESIGN, SETTING, AND PARTICIPANTS This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020. EXPOSURES Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only. MAIN OUTCOMES AND MEASURES Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up. RESULTS A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results. CONCLUSIONS AND RELEVANCE In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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Affiliation(s)
- Erik Björklund
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Carl Johan Malm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma C. Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Tygesen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Birgitta S. Romlin
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Martinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aldina Pivodic
- Statistiska Konsultgruppen, Gothenburg, Sweden
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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16
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 466] [Impact Index Per Article: 155.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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17
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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.
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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
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18
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Gaudino M, Hameed I, Robinson NB, Ruan Y, Rahouma M, Naik A, Weidenmann V, Demetres M, Y Tam D, Hare DL, Girardi LN, Biondi-Zoccai G, E Fremes S. Angiographic Patency of Coronary Artery Bypass Conduits: A Network Meta-Analysis of Randomized Trials. J Am Heart Assoc 2021; 10:e019206. [PMID: 33686866 PMCID: PMC8174193 DOI: 10.1161/jaha.120.019206] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Several randomized trials have compared the patency of coronary artery bypass conduits. All of the published studies, however, have performed pairwise comparisons and a comprehensive evaluation of the patency rates of all conduits has yet to be published. We set out to investigate the angiographic patency rates of all conduits used in coronary bypass surgery by performing a network meta-analysis of the current available randomized evidence. Methods and Results A systematic literature search was conducted for randomized controlled trials comparing the angiographic patency rate of the conventionally harvested saphenous vein, the no-touch saphenous vein, the radial artery (RA), the right internal thoracic artery, or the gastroepiploic artery. The primary outcome was graft occlusion. A total of 4160 studies were retrieved of which 14 were included with 3651 grafts analyzed. The weighted mean angiographic follow-up was 5.1 years. Compared with the conventionally harvested saphenous vein, both the RA (incidence rate ratio [IRR] 0.54; 95% CI, 0.35-0.82) and the no-touch saphenous vein (IRR 0.55; 95% CI, 0.39-0.78) were associated with lower graft occlusion. The RA ranked as the best conduit (rank score for RA 0.87 versus 0.85 for no-touch saphenous vein, 0.23 for right internal thoracic artery, 0.29 for gastroepiploic artery, and 0.25 for the conventionally harvested saphenous vein). Conclusions Compared with the conventionally harvested saphenous vein, only the RA and no-touch saphenous vein grafts are associated with significantly lower graft occlusion rates. The RA ranks as the best conduit. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020164492.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Yongle Ruan
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Ajita Naik
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Viola Weidenmann
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine New York NY
| | - Derrick Y Tam
- Schulich Heart Centre Sunnybrook Health Science University of Toronto Toronto Ontario Canada
| | - David L Hare
- Department of Cardiology Austin Health Melbourne Australia
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University Rome Italy.,Mediterranea Cardiocentro Naples Italy
| | - Stephen E Fremes
- Schulich Heart Centre Sunnybrook Health Science University of Toronto Toronto Ontario Canada
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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
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20
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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.
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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
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21
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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]
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22
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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.
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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
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23
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Kyuchukov D, Zheleva-Kyuchukova I, Nachev G. Antithrombotic regimens in patients after coronary artery bypass grafting and coronary endarterectomy. PHARMACIA 2020. [DOI: 10.3897/pharmacia.67.e52738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Coronary artery bypass grafting (CABG) remains the gold standard in the treatment of complex chronic forms of coronary heart disease (CHD). Coronary endarterectomy (CEAE) is a useful adjunctive technique to CABG in patients with diffuse coronary artery disease. In order to maintain the patency of the coronary arteries and graft conduits, various antithrombotic protocols have been introduced over the years, combining various antiplatelet and anticoagulant drugs, but still there is no consensus.
Aim: The aim of the study is to compare results between two antithrombotic regimens after CEAE. The first one is a combination of acenocoumarol combined with acetylsalicylic acid (ASA), the second regimen is a dual antiplatelet therapy (DAPT) of clopidogrel combined with ASA.
Material and methods: We retrospectively reviewed 56 consecutive patients (60 ± 8.2 years) undergoing isolated CABG in association with CEAE between January 2018 and December 2019. In the postoperative period, patients were divided into two groups according to the antithrombotic regimens described above. Twenty-four were in the ASA and acenocoumarol group (AA) and 32 were in the ASA and clopidogrel group (AC). Patients were followed up to 30 days after the operation and we access the mortality rate, new ECG changes, levels of myocardial fraction of creatinine phosphokinase (CPK-MB), left ventricular systolic function, pericardial or pleural effusions requiring drainage or revision for bleeding.
Results: Operative mortality was 3,6 %. No differences in the antithrombotic efficacy of the two regimens. A significantly higher level of hemorrhagic complications was observed in the ASA + acenocoumarol treatment group.
Conclusion: Dual antiplatelet therapy (DAPT) after CABG and coronary endarterectomy is an effective pharmacological regimen in regard to 30-day postoperative outcomes and is considerably safety in terms of bleeding complications.
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24
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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.
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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.
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25
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Nakamura M, Kimura K, Kimura T, Ishihara M, Otsuka F, Kozuma K, Kosuge M, Shinke T, Nakagawa Y, Natsuaki M, Yasuda S, Akasaka T, Kohsaka S, Haze K, Hirayama A. JCS 2020 Guideline Focused Update on Antithrombotic Therapy in Patients With Coronary Artery Disease. Circ J 2020; 84:831-865. [DOI: 10.1253/circj.cj-19-1109] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihisa Nakagawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shiga University of Medical Science
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Kazuo Haze
- Department of Cardiology, Kashiwara Municipal Hospital
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Swan D, Loughran N, Makris M, Thachil J. Management of bleeding and procedures in patients on antiplatelet therapy. Blood Rev 2020; 39:100619. [DOI: 10.1016/j.blre.2019.100619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
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Verma S, Poulter NR, Bhatt DL, Bain SC, Buse JB, Leiter LA, Nauck MA, Pratley RE, Zinman B, Ørsted DD, Monk Fries T, Rasmussen S, Marso SP. Effects of Liraglutide on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus With or Without History of Myocardial Infarction or Stroke. Circulation 2019; 138:2884-2894. [PMID: 30566004 DOI: 10.1161/circulationaha.118.034516] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The glucagon-like peptide-1 analog liraglutide reduced cardiovascular events and mortality in patients with type 2 diabetes mellitus in the LEADER trial (Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes). In a post hoc analysis, we evaluated the efficacy of liraglutide in those with and without a history of myocardial infarction (MI) and/or stroke. METHODS LEADER was a randomized trial of liraglutide (1.8 mg or maximum tolerated dose) versus placebo in 9340 patients with type 2 diabetes mellitus and high cardiovascular risk, with a median follow-up of 3.8 years. The primary outcome was a composite of cardiovascular death, nonfatal MI, or nonfatal stroke (major adverse cardiovascular events). Risk groups in this post hoc analysis were defined by history of MI/stroke, established atherosclerotic cardiovascular disease without MI/stroke, or cardiovascular risk factors alone. RESULTS Of the 9340 patients, 3692 (39.5%) had a history of MI/stroke, 3083 (33.0%) had established atherosclerotic cardiovascular disease without MI/stroke, and 2565 (27.5%) had risk factors alone. Major adverse cardiovascular events occurred in 18.8% of patients with a history of MI/stroke (incidence rate, 5.0 per 100 patient-years), 11.6% of patients with established atherosclerotic cardiovascular disease without MI/stroke (incidence rate, 3.0 per 100 patient-years), and 9.8% of patients with cardiovascular risk factors alone (incidence rate, 2.6 per 100 patient-years). Liraglutide reduced major adverse cardiovascular events in patients with a history of MI/stroke (322 of 1865 [17.3%] versus 372 of 1827 patients [20.4%]; hazard ratio, 0.85; 95% CI, 0.73-0.99) and in those with established atherosclerotic cardiovascular disease without MI/stroke (158 of 1538 [10.3%] versus 199 of 1545 patients [12.9%]; hazard ratio, 0.76; 95% CI, 0.62-0.94) compared with placebo. In patients with risk factors alone, the hazard ratio for liraglutide versus placebo was 1.08 (95% CI, 0.84-1.38, Pinteraction=0.11). Similar results were seen for secondary outcomes across risk groups. CONCLUSIONS In this post hoc analysis of patients with type 2 diabetes mellitus and high cardiovascular risk, liraglutide reduced cardiovascular outcomes both in patients with a history of MI/stroke and in those with established atherosclerotic cardiovascular disease without MI/stroke. The cardiovascular effect appeared neutral in patients with cardiovascular risk factors alone. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01179048.
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Affiliation(s)
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Stephen C Bain
- Institute of Life Science, Swansea University, United Kingdom (S.C.B.)
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | | | - Michael A Nauck
- Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N.)
| | - Richard E Pratley
- Florida Hospital Translational Research Institute for Metabolism and Diabetes, Orlando (R.E.P.)
| | - Bernard Zinman
- Lunenfeld Tanebaum Research Institute, Mount Sinai Hospital, University of Toronto, Canada (B.Z.)
| | - David D Ørsted
- Novo Nordisk A/S, Søborg, Denmark (D.D.Ø., T.M.F., S.R.)
| | - Tea Monk Fries
- Novo Nordisk A/S, Søborg, Denmark (D.D.Ø., T.M.F., S.R.)
| | | | - Steven P Marso
- Hospital Corporation of America (HCA) Midwest Health Heart & Vascular Institute, Kansas City, MO (S.P.M.)
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Ertugay S, Kudsioğlu T, Şen T. 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 2019; 27:429-450. [PMID: 32082905 PMCID: PMC7018143 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Türkan Kudsioğlu
- Anesthesiology and Reanimation, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Taner Şen
- Department of Cardiology, University of Health Sciences, Kütahya
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29
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Xenogiannis I, Tajti P, Hall AB, Alaswad K, Rinfret S, Nicholson W, Karmpaliotis D, Mashayekhi K, Furkalo S, Cavalcante JL, Burke MN, Brilakis ES. Update on Cardiac Catheterization in Patients With Prior Coronary Artery Bypass Graft Surgery. JACC Cardiovasc Interv 2019; 12:1635-1649. [DOI: 10.1016/j.jcin.2019.04.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 01/30/2023]
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Gupta S, Belley-Cote EP, Agahi P, Basha A, Jaffer I, Mehta S, Schwalm JD, Whitlock RP. Antiplatelet Therapy and Coronary Artery Bypass Grafting: Analysis of Current Evidence With a Focus on Acute Coronary Syndrome. Can J Cardiol 2019; 35:1030-1038. [DOI: 10.1016/j.cjca.2019.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 01/31/2023] Open
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Gupta S, Belley-Côté EP, Rochwerg B, Bozzo A, Panchal P, Pandey A, Mbuagbaw L, Mehta S, Schwalm JD, Whitlock RP. Antiplatelet therapy and coronary artery bypass grafting: Protocol for a systematic review and network meta-analysis. Medicine (Baltimore) 2019; 98:e16880. [PMID: 31441862 PMCID: PMC6716708 DOI: 10.1097/md.0000000000016880] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. Unfortunately, SVG are associated with poor long-term patency rates; a significant predictor of re-operation rates and survival. As such, medical therapy to prevent SVG narrowing or occlusion is of paramount importance. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. We present a protocol for a network meta-analysis (NMA) comparing the effects of various antiplatelet therapy regimens on SVG patency, mortality, and bleeding among adult patients following CABG. METHODS We will search CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC, and grey literature sources (AHA, ACC, ESC, and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. RCTs that evaluate different antiplatelet regimens at least 3-months after CABG and have any of SVG patency, mortality, MACE, and major bleeding as outcomes will be selected. We will perform title and abstract screening, full-text screening, and data extraction independently and in duplicate. Two independent reviewers will also assess risk of bias (ROB) for each study, as well as evaluate quality of evidence using the GRADE framework. We will use R to perform the NMA and use low-dose ASA as reference within our network. We will report results as odds ratios with confidence intervals for direct comparisons, and credible intervals for indirect or mixed comparisons. We will use the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. DISCUSSION Given the limited direct comparison of various antiplatelet regimens, a network approach is ideal to clarify the optimum antiplatelet therapy after CABG. We hope that our NMA will be the largest quantitative synthesis evaluating antiplatelet regimens among patients requiring CABG. It should inform clinicians and guideline developers in selecting the most effective and safest antiplatelet regimen.Systematic Review registration: International Prospective Register for Systematic Reviews (PROSPERO)-CRD42019127695.
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Affiliation(s)
- Saurabh Gupta
- Department of Surgery
- Department of Health Research Methods, Evidence and Impact
| | - Emilie P. Belley-Côté
- Department of Medicine
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact
- Department of Medicine
| | - Anthony Bozzo
- Department of Surgery
- Department of Health Research Methods, Evidence and Impact
| | | | | | | | - Shamir Mehta
- Department of Medicine
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - J-D. Schwalm
- Department of Medicine
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Richard P. Whitlock
- Department of Surgery
- Department of Health Research Methods, Evidence and Impact
- Population Health Research Institute, Hamilton, Ontario, Canada
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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.
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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
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Janiec M, Ragnarsson S, Nozohoor S. Long-term outcome after coronary endarterectomy adjunct to coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2019; 29:22-27. [DOI: 10.1093/icvts/ivy363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/22/2018] [Accepted: 11/25/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Mikael Janiec
- Department of Cardiothoracic Surgery and Anaesthesia, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Sigurdur Ragnarsson
- Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Lund University, Skåne University Hospital, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences, Lund, Department of Cardiothoracic Surgery, Lund, Lund University, Skåne University Hospital, Sweden
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Mori M, Shioda K, Bin Mahmood SU, Mangi AA, Yun JJ, Geirsson A. Dual antiplatelet therapy versus aspirin monotherapy in diabetics with stable ischemic heart disease undergoing coronary artery bypass grafting. Ann Cardiothorac Surg 2018; 7:628-635. [PMID: 30505747 DOI: 10.21037/acs.2018.08.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Dual antiplatelet therapy (DAPT) in patients presenting with acute coronary syndrome (ACS) undergoing CABG is recommended to prevent recurrent ischemic events. The benefit of DAPT post-CABG in patients with stable ischemic heart disease (SIHD) is unknown. The aim of this study was to evaluate the utilization rate of DAPT and associated outcomes in patients with SIHD undergoing CABG via a secondary analysis of Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial data. Methods In a post-hoc, nonrandomized analysis from the BARI 2D trial, we compared patients receiving DAPT and aspirin monotherapy within 90 days post-randomization. The primary outcome was the risk adjusted 5-year composite of all-cause mortality, nonfatal myocardial infarction (MI), or stroke. We analyzed patients assigned to prompt CABG treatment arm including both the insulin therapy assignments. Results Of 378 patients, within 90 days post-randomization, 59 (16%) patients received DAPT and 319 (84%) patients received aspirin alone. Cox proportional hazard analysis demonstrated that there was no significant difference in the 5-year composite event of death, MI, and stroke between DAPT and monotherapy cohorts [13 (22.0%) vs. 61 (19.1%); adjusted hazard ratio (HR): 1.06; 95% confidence interval (CI): 0.56 to 2.00; P=0.86]. There also was no significant difference at 1 year in the composite event [6 (10.2%) vs. 30 (9.4%); HR: 1.13; 95% CI: 0.46 to 2.79; P=0.79]. Conclusions The use of DAPT in patients with diabetes post-CABG in this cohort was low. Compared with aspirin monotherapy, no associated differences were observed in cardiovascular outcomes. Larger prospective studies are needed to further elucidate this observation.
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Affiliation(s)
- Makoto Mori
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Kayoko Shioda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | | | - Abeel A Mangi
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - James J Yun
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
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Ivert T, Dalén M, Ander C, Stålesen R, Lordkipanidzé M, Hjemdahl P. Increased platelet reactivity and platelet-leukocyte aggregation after elective coronary bypass surgery. Platelets 2018; 30:975-981. [PMID: 30422037 DOI: 10.1080/09537104.2018.1542122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Inflammatory mechanisms are activated, and thrombotic complications occur during the initial months after coronary artery bypass grafting (CABG). Therefore, changes over time of platelet activation and platelet-leukocyte interactions after CABG are of interest. Whole-blood flow cytometry was performed before, and 4-6 days, one month, and three months after elective CABG in 54 men with stable coronary artery disease treated with acetylsalicylic acid (ASA). Single platelets and platelet-leukocyte aggregates (PLAs) among monocytes (P-Mon), neutrophils (P-Neu), and lymphocytes (P-Lym) were studied without and with stimulation by submaximal concentrations of ADP, thrombin, and the thromboxane analog U46619. White blood cell counts were increased during the initial postoperative course, and platelet counts were increased after one month. Platelet P-selectin expression was significantly enhanced at one month when stimulated by thrombin and U46619 and at three months with ADP and thrombin. All PLAs subtypes were increased at one month without stimulation in vitro. P-Mon and P-Neu stimulated by ADP, thrombin, or U46619 were significantly increased one month after the operation but decreased compared to baseline at three months. Agonist stimulated P-Lyms were increased at one month and remained increased at three months after ADP stimulation. There was significant platelet activation and formation of PLAs unstimulated and after agonist stimulation by ADP, thrombin, and a thromboxane analog after CABG in patients with stable coronary artery disease irrespective of ASA treatment. Changes observed up to three months after CABG support further studies of the clinical implications of protracted increases in platelet activation and platelet-leukocyte interactions.
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Affiliation(s)
- Torbjörn Ivert
- Heart and Vascular Theme, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Magnus Dalén
- Heart and Vascular Theme, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Charlotte Ander
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
| | - Ragnhild Stålesen
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal,and Research center, Montreal Heart Institute , Montréal , Québec , Canada
| | - Paul Hjemdahl
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
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36
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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]
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37
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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
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38
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Chakos A, Jbara D, Singh K, Yan TD, Tian DH. Network meta-analysis of antiplatelet therapy following coronary artery bypass grafting (CABG): none versus one versus two antiplatelet agents. Ann Cardiothorac Surg 2018; 7:577-585. [PMID: 30505741 DOI: 10.21037/acs.2018.09.02] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. While clear evidence exists for the use of aspirin in maintaining graft patency, the role of dual-antiplatelet therapy in CABG patients is not as well established. This network meta-analysis aimed to compare the short-term post-CABG graft patency outcomes for patients with none, one or two antiplatelet agents. Methods Electronic databases were queried for randomized controlled trials comparing CABG graft patency rates at three months and beyond using various antiplatelet agents or placebo. Drug and graft patency data were compared using a mixed treatment comparison under a Bayesian hierarchical framework. A random-effects consistency model was applied. Direct and indirect comparisons were made between drugs and used to determine the relative efficacy for graft patency. Results The literature search identified 16 papers fulfilling the inclusion criteria, including a total of 3,133 patients with an average of 2.43 [95% confidence interval (CI): 2.20-2.66] grafts per patient. Graft types were incompletely reported, however, saphenous vein grafts (SVGs) were predominantly used [where specifically reported: 4,490 SVG, 1,226 internal mammary artery (IMA) grafts]. In all, five different agents and placebo in various regimens were compared by results of angiographic follow-up conducted at a mean of 10.4 months (95% CI: 9.28-11.5 months). Compared to placebo, aspirin alone [odds ratio (OR) 1.9; 95% credible interval (CrI): 1.3-2.8], aspirin + dipyridamole (OR 1.9; 95% CrI: 1.3-2.6), aspirin + clopidogrel (OR 2.9; 95% CrI: 1.5-5.7) and aspirin + ticagrelor (OR 3.8; 95% CrI: 1.2-13.0) significantly improved graft patency. When compared to aspirin monotherapy, aspirin + clopidogrel (OR 1.6; 95% CrI: 0.86-2.7) and aspirin + ticagrelor (OR 2.0; 95% CrI: 0.69-6.3) had OR that suggested a trend favoring patency compared to aspirin monotherapy, however, these results did not reach significance. Sub-group analysis of SVG graft patency was unable to reach significance (only eight studies with six treatment comparisons were evaluated). Secondary endpoints of death, bleeding, myocardial infarction and cerebrovascular accident were incompletely reported and were pooled but not compared between drug treatment arms. Conclusions Aspirin monotherapy and dual antiplatelet therapy (DAPT) provided significant all-graft patency benefit compared to placebo at three months and beyond. A trend existed for DAPT to improve graft patency compared to aspirin, although this did not reach statistical significance. Further randomized controlled studies comparing aspirin monotherapy to DAPT are required to determine the utility of DAPT in CABG patients for maintaining graft patency.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Dean Jbara
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Kamal Singh
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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Karhausen JA, Qi W, Smeltz AM, Li YJ, Shah SH, Kraus WE, Mathew JP, Podgoreanu MV, Kertai MD. Genome-Wide Association Study Links Receptor Tyrosine Kinase Inhibitor Sprouty 2 to Thrombocytopenia after Coronary Artery Bypass Surgery. Thromb Haemost 2018; 118:1572-1585. [PMID: 30103242 DOI: 10.1055/s-0038-1667199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Thrombocytopenia after cardiac surgery independently predicts stroke, acute kidney injury and death. To understand the underlying risks and mechanisms, we analysed genetic variations associated with thrombocytopenia in patients undergoing coronary artery bypass grafting (CABG) surgery. MATERIALS AND METHODS Study subjects underwent isolated on-pump CABG surgery at Duke University Medical Center. Post-operative thrombocytopenia was defined as platelet count < 100 × 109/L. Using a logistic regression model adjusted for clinical risk factors, we performed a genome-wide association study in a discovery cohort (n = 860) and validated significant findings in a replication cohort (n = 296). Protein expression was assessed in isolated platelets by immunoblot. RESULTS A total of 63 single-nucleotide polymorphisms met a priori discovery thresholds for replication, but only 1 (rs9574547) in the intergenic region upstream of sprouty 2 (SPRY2) met nominal significance in the replication cohort. The minor allele of rs9574547 was associated with a lower risk for thrombocytopenia (discovery cohort, odds ratio, 0.45, 95% confidence interval, 0.30-0.67, p = 9.76 × 10-5) with the overall association confirmed by meta-analysis (meta-p = 7.88 × 10-6). Immunoblotting demonstrated expression of SPRY2 and its dynamic regulation during platelet activation. Treatment with a functional SPRY2 peptide blunted platelet extracellular signal-regulated kinase (ERK) phosphorylation after agonist stimulation. CONCLUSION We identified the association of a genetic polymorphism in the intergenic region of SPRY2 with a decreased incidence of thrombocytopenia after CABG surgery. Because SPRY2-an endogenous receptor tyrosine kinase inhibitor-is present in platelets and modulates essential signalling pathways, these findings support a role for SPRY2 as a novel modulator of platelet responses after cardiac surgery.
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Affiliation(s)
- Jörn A Karhausen
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Wenjing Qi
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Alan M Smeltz
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Svati H Shah
- Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - William E Kraus
- Molecular Physiology Institute, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Joseph P Mathew
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States
| | - Miklos D Kertai
- Department of Anesthesiology, Duke Perioperative Genomics Program, Duke University Medical Center, Duke University, Durham, North Carolina, United States.,Department of Anesthesiology, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tennessee, United States
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40
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Yang Z, Xie Z, Pei X, Quan X, Feng D. Effect of thrombelastography on timing of coronary artery bypass grafting. Exp Ther Med 2018; 16:579-584. [PMID: 30116315 PMCID: PMC6090235 DOI: 10.3892/etm.2018.6202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/28/2018] [Indexed: 01/30/2023] Open
Abstract
The guiding value of thrombelastography (TEG) on the selection of surgical timing for patients scheduled for coronary artery bypass grafting (CABG) was investigated. A total of 90 subjects with acute coronary syndrome (ACS) treated between February 2014 and December 2016 in Henan Provincial People's Hospital were recruited. The patients received dual antiplatelet therapy (DAPT) and were scheduled for CABG. Subjects were randomly allocated into two groups, TEG group (n=45) and non-TEG group (n=45). Patients in the TEG group withheld medications at 24 h prior to surgery and received TEG examination. Based on maximum amplitude of adenosine diphosphate (MAADP), subjects were further grouped into three sub-groups with MAADP <35 mm, 35–50 mm, and >50 mm, and accordingly received CABG within 1 day, 3–5 days and 5 days later, respectively. Subjects in the control group (non-TEG group) received CABG 5–7 days after medication withdrawal. Chest drainage volume within 24 h after surgery and red blood cell transfusion during perioperative period were compared. Other recorded parameters were incubation period, intensive care unit length of stay, hospital stay, incidence of 30-day adverse events and readmission rate. The average waiting time before CABG for patients of TEG group was shorter compared with the commonly recommended time. The red blood cell transfusions during perioperative period of subjects in TEG group and non-TEG group were significantly different (P=0.23). The median hospital stay of subjects in TEG group was shorter than that of non-TEG group (P=0.037). The bleeding amount of patients in TEG group was 220.16±80.56 ml, which was significantly lower than that of non-TEG group (435.29±90.16). The difference was statistically significant (P=0.032). The results suggested that TEG assay-based evaluation of platelet function for patients scheduled for CABG reasonably guides surgeons with appropriate surgical timing and reduces the amount of time patients wait to be treated.
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Affiliation(s)
- Zhiyuan Yang
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Zhouliang Xie
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Xueliang Pei
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Xiaoqiang Quan
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Deguang Feng
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
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41
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Benedetto U, Altman DG, Gerry S, Gray A, Lees B, Flather M, Taggart DP. Impact of dual antiplatelet therapy after coronary artery bypass surgery on 1-year outcomes in the Arterial Revascularization Trial. Eur J Cardiothorac Surg 2018; 52:456-461. [PMID: 28387790 DOI: 10.1093/ejcts/ezx075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/12/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES There is still little evidence to boldport routine dual antiplatelet therapy (DAPT) with P2Y12 antagonists following coronary artery bypass grafting (CABG). The Arterial Revascularization Trial (ART) was designed to compare 10-year survival after bilateral versus single internal thoracic artery grafting. We aimed to get insights into the effect of DAPT (with clopidogrel) following CABG on 1-year outcomes by performing a post hoc ART analysis. METHODS Among patients enrolled in the ART (n = 3102), 609 (21%) and 2308 (79%) were discharged on DAPT or aspirin alone, respectively. The primary end-point was the incidence of major adverse cerebrovascular and cardiac events (MACCE) at 1 year including cardiac death, myocardial infarction, cerebrovascular accident and reintervention; safety end-point was bleeding requiring hospitalization. Propensity score (PS) matching was used to create comparable groups. RESULTS Among 609 PS-matched pairs, MACCE occurred in 34 (5.6%) and 34 (5.6%) in the DAPT and aspirin alone groups, respectively, with no significant difference between the 2 groups [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.59-1.59; P = 0.90]. Only 188 (31%) subjects completed 1 year of DAPT, and in this subgroup, MACCE rate was 5.8% (HR 1.11, 95% CI 0.53-2.30; P = 0.78). In the overall sample, bleeding rate was higher in DAPT group (2.3% vs 1.1%; P = 0.02), although this difference was no longer significant after matching (2.3% vs 1.8%; P = 0.54). CONCLUSIONS Based on these findings, when compared with aspirin alone, DAPT with clopidogrel prescribed at discharge was not associated with a significant reduction of adverse cardiac and cerebrovascular events at 1 year following CABG.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alastair Gray
- Department of Public Health, Health Economics Research Centre, University of Oxford, Headington, Oxford, UK
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Marcus Flather
- Research and Development Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the strengths and weaknesses of systematic reviews and meta-analyses to inform our current understanding of cardiac surgery. RECENT FINDINGS A systematic review and meta-analysis of a focused topic can provide a quantitative estimate for the effect of a treatment intervention or exposure. In cardiac surgery, observational studies and small, single-center prospective trials provide most of the clinical outcomes that form the evidence base for patient management and guideline recommendations. As such, meta-analyses can be particularly valuable in synthesizing the literature for a particular focused surgical question. Since the year 2000, there are over 800 meta-analysis-related publications in our field. There are some limitations to this technique, including clinical, methodological and statistical heterogeneity, among other challenges. Despite these caveats, results of meta-analyses have been useful in forming treatment recommendations or in providing guidance in the design of future clinical trials. SUMMARY There is a growing number of meta-analyses in the field of cardiac surgery. Knowledge translation via meta-analyses will continue to guide and inform cardiac surgical practice and our practice guidelines.
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Affiliation(s)
- Bobby Yanagawa
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital
| | - Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, St Michael's Hospital
| | - Andrea C Tricco
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Mori M, Shioda K, Yun JJ, Mangi AA, Darr U, Geirsson A. Pattern and predictors of dual antiplatelet use after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2018; 155:632-638. [DOI: 10.1016/j.jtcvs.2017.09.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 08/28/2017] [Accepted: 09/19/2017] [Indexed: 11/26/2022]
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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.
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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.
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Eight-year follow-up of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial. J Thorac Cardiovasc Surg 2018; 155:212-222.e2. [DOI: 10.1016/j.jtcvs.2017.06.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 05/18/2017] [Accepted: 06/14/2017] [Indexed: 11/17/2022]
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46
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Zhao Y, Peng H, Li X, Qin Y, Cao F, Peng D, Liu J. Dual antiplatelet therapy after coronary artery bypass surgery: is there an increase in bleeding risk? A meta-analysis. Interact Cardiovasc Thorac Surg 2017; 26:573-582. [PMID: 29237042 DOI: 10.1093/icvts/ivx374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/27/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Yejing Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongyu Peng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaonan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujun Qin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fangying Cao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ding Peng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Goli RR, Contractor MM, Nathan A, Tuteja S, Kobayashi T, Giri J. Antiplatelet Therapy for Secondary Prevention of Vascular Disease Complications. Curr Atheroscler Rep 2017; 19:56. [DOI: 10.1007/s11883-017-0698-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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A 10-year institutional experience with open branched graft reconstruction of aortic aneurysms in connective tissue disorders versus degenerative disease. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.451] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:5-33. [PMID: 29029110 DOI: 10.1093/ejcts/ezx314] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN, Badimon L, Vranckx P, Agewall S, Andreotti F, Antman E, Barbato E, Bassand JP, Bugiardini R, Cikirikcioglu M, Cuisset T, De Bonis M, Delgado V, Fitzsimons D, Gaemperli O, Galiè N, Gilard M, Hamm CW, Ibanez B, Iung B, James S, Knuuti J, Landmesser U, Leclercq C, Lettino M, Lip G, Piepoli MF, Pierard L, Schwerzmann M, Sechtem U, Simpson IA, Uva MS, Stabile E, Storey RF, Tendera M, Van de Werf F, Verheugt F, Aboyans V. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg 2017; 53:34-78. [DOI: 10.1093/ejcts/ezx334] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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