Key result
Continuation of dual antiplatelet therapy until 0-1 days prior to coronary artery bypass grafting was associated with a higher incidence of surgical re-exploration for bleeding compared to discontinuation 5 days prior.
Why the study?
The impact of ticagrelor or clopidogrel and their discontinuation intervals on postoperative bleeding and surgical re-exploration after CABG needed evaluation.
Does continuing dual antiplatelet therapy (clopidogrel or ticagrelor) until shortly before surgery increase bleeding complications in patients undergoing coronary artery bypass grafting?
Cohort (n=190)
No
Does continuing dual antiplatelet therapy (clopidogrel or ticagrelor) until shortly before surgery increase bleeding complications in patients undergoing coronary artery bypass grafting?
Continuing dual antiplatelet therapy until 0-1 days before CABG, particularly with ticagrelor, significantly increases the risk of major bleeding and surgical re-exploration compared to discontinuation at 5 days.
Answers are grounded in this paper and cite their sources.
Should not yet change DAPT discontinuation practices before CABG; leaves open optimal interval for bleeding risk.
Aim: To evaluate retrospectively the impact of ticagrelor or clopidogrel in patients taking dual antiplatelet aggregation therapy (DAPT, ASA + clopidogrel or ticagrelor) undergoing coronary artery bypass grafting (CABG) on postoperative bleeding complications and need for mediastinal surgical re-exploration, focusing on the interval of discontinuation of DAPT. Material and methods: From January 2017 to January 2018, 190 patients underwent coronary artery bypass grafting with DAPT discontinuation 5 days (group 1, n = 82), 2-4 days (group 2, n = 84), or 0-1 days (group 3, n = 24) prior to CABG. Results: As compared to group 1, blood loss from chest tube drainages at 24 hours was significantly higher in groups 2 and 3 (480 238 vs. 512 209 vs. 640 253 ml; p = 0.007 and p = 0.016). Incidence of surgical re-exploration for bleeding was 1.2% in group 1, 2.4% in group 2, 12.5% in group 3 (p = 0.014). Independent predictors of surgical re-exploration were group 3 (p = 0.05; HR = 9.2) and preoperative increased value of creatinine serum level (p = 0.02; HR = 1.3). In group 3, the incidence of re-exploration was 5.6% (1/18) in patients taking ASA + clopidogrel, 33.3% (2/6) in those taking ASA + ticagrelor (HR-32), respectively (p < 0.001). Operative mortality was 1.2% in group 1, 1.2% in group 2, absent in group 3 (p = not significant). Conclusions: Continued DAPT intake until CABG shows a clear trend towards more bleeding complications when compared with its discontinuation. Major blood loss and surgical reexploration were not associated with an increased risk of operative mortality. Ticagrelor intake confers a higher risk of bleeding in comparison with clopidogrel; by stopping its intake at least 2 days prior to surgery, an increased risk of bleeding complications is not observed.
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Nardi et al. (2019) conducted a cohort in Multivessel coronary artery disease (n=190). DAPT discontinuation 0-1 days prior to CABG vs. DAPT discontinuation 5 days prior to CABG was evaluated on Surgical re-exploration for bleeding (HR 9.2, 95% CI 0.866-97.98, p=0.05). Continuation of dual antiplatelet therapy until 0-1 days prior to coronary artery bypass grafting was associated with a higher incidence of surgical re-exploration for bleeding compared to discontinuation 5 days prior.
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