Emerging constructs to maintain safety among patients with acute coronary syndromes requiring surgical coronary revascularization

Pharmacotherapies directed towards well-defined biochemical processes underlying coronary atherothrombosis have favourably influenced the natural history of disease; however, coronary revascularization is still required in 0–15 percent of patients admitted to the hospital with acute coronary syndromes. Because surgical coronary revascularization has a profound impact on haemostasis, especially when cardiopulmonary bypass (CPB) is employed, antithrombotic and antiplatelet therapies must be chosen carefully during the peri-operative period. Though the potential benefit of platelet P2Y12-receptor inhibition in this particular patient population is recognized widely, the available evidence show that adenosine-diphosphate-mediated platelet activation is an absolute prerequisite for post-operative haemostasis. Pharmacotherapies in development that have rapid onset and offset of P2Y12 inhibition may allow much-needed flexibility in the perioperative setting. Alternative anticoagulants to unfractionated heparin that attenuate thrombin-mediated haemostatic derangements may add further to the optimal pharmacological management of patients undergoing coronary revascularization.