Key result
Platelet reactivity-guided CABG timing is noninferior to standard P2Y12 inhibitor withdrawal for 24-hour bleeding.
Why the study?
Guidelines recommend stopping clopidogrel at least 5 days before CABG in ACS patients, a waiting period with clinical and economic implications, and whether a platelet reactivity-based strategy is noninferior to standard care for 24-h post-CABG bleeding required evaluation.
Does a platelet reactivity-guided strategy for timing CABG maintain noninferiority for 24-hour post-operative bleeding compared to standard 5-to-7-day P2Y12 inhibitor withdrawal in patients with acute coronary syndromes awaiting surgical revascularization?
RCT (n=190)
Open-label
Randomized
Does a platelet reactivity-guided strategy for timing CABG maintain noninferiority for 24-hour post-operative bleeding compared to standard 5-to-7-day P2Y12 inhibitor withdrawal in patients with acute coronary syndromes awaiting surgical revascularization?
Answers are grounded in this paper and cite their sources.
In ACS patients on DAPT awaiting CABG, a platelet reactivity-guided timing strategy is noninferior to standard 5-to-7-day P2Y12 inhibitor washout for peri-operative bleeding while significantly shortening wait times and lowering hospital expenses.
BACKGROUND Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Approximately 10% to 15% of these patients will undergo coronary artery bypass graft (CABG) surgery for index events, and current guidelines recommend stopping clopidogrel at least 5 days before CABG. This waiting time has clinical and economic implications. OBJECTIVES This study aimed to evaluate if a platelet reactivity-based strategy is noninferior to standard of care for 24-h post-CABG bleeding. METHODS In this randomized, open label noninferiority trial, 190 patients admitted with ACS with indications for CABG and on aspirin and P2Y12 receptor inhibitors, were assigned to either control group, P2Y12 receptor inhibitor withdrawn 5 to 7 days before CABG, or intervention group, daily measurements of platelet reactivity by Multiplate analyzer (Roche Diagnostics GmbH, Vienna, Austria) with CABG planned the next working day after platelet reactivity normalization (pre-defined as ≥46 aggregation units). RESULTS Within the first 24 h of CABG, the median chest tube drainage was 350 ml (interquartile range [IQR]: 250 to 475 ml) and 350 ml (IQR: 255 to 500 ml) in the intervention and control groups, respectively (p for noninferiority <0.001). The median waiting period between the decision to undergo CABG and the procedure was 112 h (IQR: 66 to 142 h) and 136 h (IQR: 112 to 161 h) (p < 0.001), respectively. In the intention-to-treat analysis, a 6.4% decrease in the median in-hospital expenses was observed in the intervention group (p = 0.014), with 11.2% decrease in the analysis per protocol (p = 0.003). CONCLUSIONS A strategy based on platelet reactivity-guided is noninferior to the standard of care in patients with ACS awaiting CABG regarding peri-operative bleeding, significantly shortens the waiting time to CABG, and decreases hospital expenses. (Evaluation of Platelet Aggregability in the Release of CABG in Patients With ACS With DAPT; NCT02516267).
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Nakashima et al. (2021) conducted an RCT in Acute coronary syndromes awaiting surgical revascularization (CABG) (n=190). Platelet reactivity-guided CABG timing strategy (daily Multiplate analyzer measurements, CABG planned next working day after platelet reactivity ≥46 aggregation units) vs. Standard of care (P2Y12 receptor inhibitor withdrawn 5 to 7 days before CABG) was evaluated on 24-hour post-CABG bleeding (median chest tube drainage) (p=<0.001 for noninferiority). Platelet reactivity-guided CABG timing was noninferior to standard 5-7 day P2Y12 inhibitor withdrawal for 24-h post-CABG bleeding.
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