The Use of Point-of-care Testing in Detecting Platelet Function Recovery in a Patient Treated with Prasugrel Undergoing Urgent Surgical Revascularization

INTRODUCTIONPreoperative administration of dual antiplatelet therapy (DAPT) in patients undergoing urgent coronary artery bypass grafting (CABG) surgery remains controversial. DAPT including aspirin and a P2Y12-inhibitor is most administered before urgent CABG in the setting of acute coronary syndrome (ACS) in accordance with the current guidelines [1]. Although preoperative P2Y12-inhibitor treatment is associated with reduced occurrence of ischemic events, there is a clear evidence that it can increase the risk of surgery-related bleeding, especially in the case of the third-generation thienopyridines such as prasugrel [2]. Current guidelines recommend a discontinuation of prasugrel a minimum of 7 days before non-emergent cardiac surgery to allow the recovery of platelet function and attenuate the risk of perioperative bleeding [1].However, these recommendations do not account for highly variable recovery of platelet reactivity following discontinuation of P2Y12-inhibitor [3]. Prasugrel is an inactive prodrug that is transformed into its active metabolite with a half-life of 7 hours and results in a faster, more consistent platelet inhibition, when compared to clopidogrel [1,2,4]. Preoperative point-of-care (POC) platelet function testing (PFT) in patients receiving prasugrel could be helpful to measure platelet reactivity and predict the risk of perioperative bleeding and transfusion requirements [5-8]. We presented a rare case of unexpected complete platelet function recovery in a patient with ACS treated with prasugrel and revealed by preoperative platelet function monitoring with thromboelastography (TEG) platelet mapping before urgent surgical coronary revascularization.