What does this research mean for the field?

Recent preoperative dual antiplatelet therapy within 48 hours before urgent coronary artery bypass grafting is independently associated with increased risks of surgical reintervention, blood transfusion, and operative mortality. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To evaluate the impact of recent preoperative dual antiplatelet therapy on surgical bleeding and postoperative outcomes in patients undergoing urgent coronary artery bypass grafting following acute coronary syndrome.

October 15, 2025JTCVS OpenOpen Access

Preoperative dual antiplatelet therapy increases risk after urgent coronary bypass surgery: A Netherlands heart registration study

Q: What are the key findings of this study?

Recent dual antiplatelet therapy exposure within 48 hours before urgent CABG significantly increased the risk of bleeding-related reinterventions (OR 1.78) compared to aspirin alone.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Urgent coronary artery bypass grafting (CABG) after acute coronary syndrome (n=6913). Intervention: Dual antiplatelet therapy (DAPT) within 48 hours preoperatively vs. Single antiplatelet therapy (aspirin alone). Primary outcome: Reintervention within 30 days due to bleeding/tamponade (OR 1.78, 95% CI 1.33-2.39, p=<0.001).

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Key result

Pre-CABG DAPT exposure linked to ~78% higher odds of bleeding reinterventions vs aspirin alone.

OR 1.78
95% CI 1.33-2.39
P<0.001
n=6,913

Why the study?

Perioperative management of dual antiplatelet therapy before urgent CABG after acute coronary syndrome remains controversial.

Does recent preoperative dual antiplatelet therapy (within 48 hours) increase the risk of perioperative bleeding complications and mortality compared to aspirin alone in patients undergoing urgent CABG after an acute coronary syndrome?

Key Points

To evaluate the impact of recent preoperative dual antiplatelet therapy on surgical bleeding and postoperative outcomes in patients undergoing urgent coronary artery bypass grafting following acute coronary syndrome.
Analyzed data from the nationwide Netherlands Heart Registration for 6913 patients undergoing urgent isolated CABG within 90 days of acute coronary syndrome across 16 Dutch heart centers.
Compared patients receiving dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor within 48 hours preoperatively; n=2721) with those receiving single antiplatelet therapy (aspirin alone; n=4192).
Applied propensity score matching (2390 patients per group) and multivariable logistic regression adjusted for EuroSCORE II, recent PCI, and treatment center.
Recent DAPT was independently associated with increased reintervention within 30 days due to bleeding or tamponade (7.1% vs 3.7%; OR, 1.78; 95% CI, 1.33-2.39; P < .001).
The composite transfusion end point occurred more frequently with DAPT than with aspirin alone (44.9% vs 27.0%; OR, 1.85; 95% CI, 1.61-2.13; P < .001).
Surgical mortality was significantly higher in the DAPT group compared to the single antiplatelet group (1.7% vs 0.9%; OR, 2.02; 95% CI, 1.15-3.55; P = .01), while institutional DAPT use ranged from 12.3% to 84.4% (P < .001).

Study Design

Type

Cohort (n=6,913)

Multicenter

Yes

Structured PICO

Population

6,913 adult patients with recent acute coronary syndrome undergoing urgent isolated CABG, evaluated retrospectively for 30-day perioperative bleeding and mortality outcomes.

Exposure

Dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) administered within 48 hours before surgery.

Comparator

Single antiplatelet therapy (SAPT) consisting of aspirin only, administered within 48 hours before surgery.

Outcome

1) Number of reinterventions within 30 days postoperatively caused by bleeding or tamponade; 2) Composite transfusion-related end point including any transfusion of red blood cells, platelets, fresh-frozen plasma, and/or administration of coagulation products (e.g., fibrinogen, prothrombin complex concentrate).safety

Main Result

Odds Ratio: 1.78 (95% CI 1.33–2.39)

Absolute Event Rate: 6.3% vs 3.1%

p-value: p=<0.001

Continuing dual antiplatelet therapy within 48 hours of urgent CABG following acute coronary syndrome substantially increases the risk of bleeding reinterventions, transfusions, and short-term mortality compared with aspirin alone.

Limitations

Retrospective observational design limits the ability to establish causal relationships.
Potential residual confounding from unmeasured variables despite propensity score matching.
Lack of detailed information on the exact timing of P2Y12 inhibitor discontinuation within the 48-hour window.
No data available on platelet function testing.
Registry records 30-day outcomes but cannot distinguish between early (<72 hours) and late (>72 hours) events.
Lack of granular details regarding surgical techniques and specific hemostatic strategies at different centers.
Retrospective observational design limits ability to establish causal relationships and risks residual confounding
Lack of detailed information on exact timing of P2Y12 inhibitor discontinuation (grouped broadly within 48 hours before surgery)
Lack of data on platelet function testing
Inability to distinguish between early (<72 hours) and late (>72 hours) reinterventions or transfusions within the 30-day timeframe
Lack of granular details regarding surgical technique and hemostatic strategies

Implication

May warrant DAPT cessation caution before urgent CABG; leaves open optimal preoperative strategy pending randomized trials.

Abstract

Objective: Dual antiplatelet therapy (DAPT) is standard care after acute coronary syndrome, but its perioperative management before urgent coronary artery bypass grafting (CABG) remains controversial. By using data from the Netherlands Heart Registration, a nationwide Dutch registry, we sought to assess the impact of recent preoperative DAPT on surgical and postoperative outcomes in patients undergoing urgent CABG after acute coronary syndrome. Methods: In this multicenter retrospective cohort study, 6913 patients undergoing urgent isolated CABG within 90 days of acute coronary syndrome were analyzed. Patients receiving DAPT (aspirin + P2Y12 inhibitor within 48 hours preoperatively) were compared with those on aspirin alone. Propensity score matching and multivariable logistic regression were used to adjust for confounding. Results: Recent DAPT use was independently associated with increased perioperative bleeding complications, including greater rates of reintervention (odds ratio [OR], 1.78), transfusion (OR, 1.85), and surgical mortality (OR, 2.02). Considerable interhospital variation in DAPT use (12%-84%) underscores inconsistent practices across Dutch cardiac surgery centers. Conclusions: Recent DAPT before urgent CABG is independently associated with significantly increased perioperative bleeding risk, transfusion requirements, and mortality. The substantial interhospital variation in DAPT use across Dutch cardiac surgery centers further underscores the need for standardized, evidence-based guidelines to optimize antiplatelet management in high-risk patients with coronary syndrome requiring surgical revascularization.

Discussion

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Published by JTCVS Open · CC BY

Cite This Study

Apostel et al. (2025) conducted a cohort in Urgent coronary artery bypass grafting (CABG) after acute coronary syndrome (n=6,913). Dual antiplatelet therapy (DAPT) within 48 hours preoperatively vs. Single antiplatelet therapy (aspirin alone) was evaluated on Reintervention within 30 days due to bleeding/tamponade (OR 1.78, 95% CI 1.33-2.39, p=<0.001). Recent dual antiplatelet therapy exposure within 48 hours before urgent CABG significantly increased the risk of bleeding-related reinterventions (OR 1.78) compared to aspirin alone.

synapsesocial.com/papers/6a0f6d8e28c2d29469fe194e https://doi.org/10.1016/j.xjon.2025.09.045

Topics

Dual antiplatelet therapy

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Implication

May warrant DAPT cessation caution before urgent CABG; leaves open optimal preoperative strategy pending randomized trials.

Preoperative dual antiplatelet therapy increases risk after urgent coronary bypass surgery: A Netherlands heart registration study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Figures from the paper

Cite This Study

Topics

Preoperative dual antiplatelet therapy increases risk after urgent coronary bypass surgery: A Netherlands heart registration study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Figures from the paper

Cite This Study

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