open access

Vol 76, No 6 (2018)
Reviews
Published online: 2018-05-17
Submitted: 2018-05-14
Accepted: 2018-05-14
Get Citation

Antiplatelet therapy for patients undergoing coronary artery bypass surgery

Christine M. DeStephan, David J. Schneider
DOI: 10.5603/KP.a2018.0111
·
Kardiol Pol 2018;76(6):945-952.

open access

Vol 76, No 6 (2018)
Reviews
Published online: 2018-05-17
Submitted: 2018-05-14
Accepted: 2018-05-14

Abstract

Considerable variation in the use and duration of antiplatelet medications during the perioperative and postoperative care of patients undergoing coronary artery bypass grafting (CABG) reflects the limited number of studies focused directly on these patients as well as the variation in the results reported. In this review we highlight the incidence and mechanisms of graft closure as well as the evidence in support of antiplatelet therapy that is balanced by the impact of antiplatelet therapy on the risk of bleeding to provide recommendations for the use of this therapy in patients undergoing CABG. Low-dose acetylsalicylic acid (ASA; ≤ 160 mg daily) reduces the incidence of perioperative myocardial infarction, acute renal injury, and mortality without increasing the risk of bleeding and so is recommended both before and after CABG. The use of dual antiplatelet therapy with ASA plus a P2Y12 antagonist adds a greater risk of bleeding. While additional studies are required, we can make the following recommendations: because of increased bleeding and mortality when patients are treated with clopidogrel preoperatively, CABG should be delayed for five days. Because of increased bleeding when patients are treated with ticagrelor preoperatively, CABG should be delayed for three days. Because of increased bleeding when patients are treated with prasugrel preopera­tively, CABG should be delayed for seven days. For patients who had a coronary stent placed preoperatively or had an acute coronary syndrome preoperatively, resumption of therapy with their P2Y12 antagonist postoperatively for 12 months reduces the subsequent incidence of cardiovascular events.

Abstract

Considerable variation in the use and duration of antiplatelet medications during the perioperative and postoperative care of patients undergoing coronary artery bypass grafting (CABG) reflects the limited number of studies focused directly on these patients as well as the variation in the results reported. In this review we highlight the incidence and mechanisms of graft closure as well as the evidence in support of antiplatelet therapy that is balanced by the impact of antiplatelet therapy on the risk of bleeding to provide recommendations for the use of this therapy in patients undergoing CABG. Low-dose acetylsalicylic acid (ASA; ≤ 160 mg daily) reduces the incidence of perioperative myocardial infarction, acute renal injury, and mortality without increasing the risk of bleeding and so is recommended both before and after CABG. The use of dual antiplatelet therapy with ASA plus a P2Y12 antagonist adds a greater risk of bleeding. While additional studies are required, we can make the following recommendations: because of increased bleeding and mortality when patients are treated with clopidogrel preoperatively, CABG should be delayed for five days. Because of increased bleeding when patients are treated with ticagrelor preoperatively, CABG should be delayed for three days. Because of increased bleeding when patients are treated with prasugrel preopera­tively, CABG should be delayed for seven days. For patients who had a coronary stent placed preoperatively or had an acute coronary syndrome preoperatively, resumption of therapy with their P2Y12 antagonist postoperatively for 12 months reduces the subsequent incidence of cardiovascular events.

Get Citation

Keywords

coronary artery bypass grafting, antiplatelet therapy, acetylsalicylic acid, clopidogrel

About this article
Title

Antiplatelet therapy for patients undergoing coronary artery bypass surgery

Journal

Kardiologia Polska (Polish Heart Journal)

Issue

Vol 76, No 6 (2018)

Pages

945-952

Published online

2018-05-17

DOI

10.5603/KP.a2018.0111

Bibliographic record

Kardiol Pol 2018;76(6):945-952.

Keywords

coronary artery bypass grafting
antiplatelet therapy
acetylsalicylic acid
clopidogrel

Authors

Christine M. DeStephan
David J. Schneider

References (62)
  1. Greenland P, Knoll MD, Stamler J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA. 2003; 290(7): 891–897.
  2. Campeau L, Enjalbert M, Lespérance J, et al. The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation. A study 10 years after aortocoronary bypass surgery. N Engl J Med. 1984; 311(21): 1329–1332.
  3. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986; 314(1): 1–6.
  4. Fitzgibbon GM, Kafka HP, Leach AJ, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and reoperation in 1,388 patients during 25 years. J Am Coll Cardiol. 1996; 28(3): 616–626.
  5. Alexander JH, Hafley G, Harrington RA, et al. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT IV: a randomized controlled trial. JAMA. 2005; 294(19): 2446–2454.
  6. Bourassa MG, Fisher LD, Campeau L, et al. Long-term fate of bypass grafts: the Coronary Artery Surgery Study (CASS) and Montreal Heart Institute experiences. Circulation. 1985; 72(6 Pt 2): V71–V78.
  7. Campeau L, Lespérance J, Hermann J, et al. Loss of the improvement of angina between 1 and 7 years after aortocoronary bypass surgery: correlations with changes in vein grafts and in coronary arteries. Circulation. 1979; 60(2 Pt 2): 1–5.
  8. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: pathogenesis, predisposition, and prevention. Circulation. 1998; 97(9): 916–931.
  9. McGeachie JK, Meagher S, Prendergast FJ. Vein-to-artery grafts: the long-term development of neo-intimal hyperplasia and its relationship to vasa vasorum and sympathetic innervation. Aust N Z J Surg. 1989; 59(1): 59–65.
  10. Angelini GD, Passani SL, Breckenridge IM, et al. Nature and pressure dependence of damage induced by distension of human saphenous vein coronary artery bypass grafts. Cardiovasc Res. 1987; 21(12): 902–907.
  11. Kennedy JH, Lever MJ, Addis BJ, et al. Changes in vein interstitium following distension for aortocoronary bypass. J Cardiovasc Surg (Torino). 1989; 30(6): 992–995.
  12. Chesebro J, Fuster V, Elveback L, et al. Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations. N Engl J Med. 1984; 310(4): 209–214.
  13. Allaire E, Clowes AW. Endothelial cell injury in cardiovascular surgery: the intimal hyperplastic response. Ann Thorac Surg. 1997; 63(2): 582–591.
  14. Nwasokwa ON. Coronary artery bypass graft disease. Ann Intern Med. 1995; 123(7): 528–545.
  15. Schwartz SM, deBlois D, O'Brien ER. The intima. Soil for atherosclerosis and restenosis. Circ Res. 1995; 77(3): 445–465.
  16. Zhang L, Peppel K, Brian L, et al. Vein graft neointimal hyperplasia is exacerbated by tumor necrosis factor receptor-1 signaling in graft-intrinsic cells. Arterioscler Thromb Vasc Biol. 2004; 24(12): 2277–2283.
  17. Stary HC, Blankenhorn DH, Chandler AB, et al. A definition of the intima of human arteries and of its atherosclerosis- prone regions. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation. 1992; 85(1): 391–405.
  18. Hong YJ, Jeong MHo, Ahn Y, et al. Impact of lesion location on intravascular ultrasound findings and short-term and five-year long-term clinical outcome after percutaneous coronary intervention for saphenous vein graft lesions. Int J Cardiol. 2013; 167(1): 29–33.
  19. Sano K, Mintz GS, Carlier SG, et al. Intravascular ultrasonic differences between aorto-ostial and shaft narrowing in saphenous veins used as aortocoronary bypass grafts. Am J Cardiol. 2006; 97(10): 1463–1466.
  20. LoGerfo FW, Quist WC, Cantelmo NL, et al. Integrity of vein grafts as a function of initial intimal and medial preservation. Circulation. 1983; 68(3 Pt 2): II117–II124.
  21. Chesebro JH, Clements IP, Fuster V, et al. A Platelet-Inhibitor-Drug Trial in Coronary-Artery Bypass Operations. N Engl J Med. 1982; 307(2): 73–78.
  22. Goldman S, Copeland J, Moritz T, et al. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. Circulation. 1988; 77(6): 1324–1332.
  23. Dacey L, Munoz J, Johnson E, et al. Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients. Ann Thorac Surg. 2000; 70(6): 1986–1990.
  24. Mangano DT. Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002; 347(17): 1309–1317.
  25. Hastings S, Myles P, McIlroy D. Aspirin and coronary artery surgery: a systematic review and meta-analysis. Br J Anaesth. 2015; 115(3): 376–385.
  26. Aboul-Hassan SS, Stankowski T, Marczak J, et al. The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis. J Card Surg. 2017; 32(12): 758–774.
  27. Wijns W, Kolh P, Danchin N, et al. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2010; 31(20): 2501–2555.
  28. Hillis LD, Smith PK, Anderson JL, et al. American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, Society of Thoracic Surgeons. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011; 58(24): e123–e210.
  29. Jiang XL, Samant S, Lesko LJ, et al. Clinical pharmacokinetics and pharmacodynamics of clopidogrel. Clin Pharmacokinet. 2015; 54(2): 147–166.
  30. Yusuf S, Zhao F, Mehta SR, et al. Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001; 345(7): 494–502.
  31. Fox KAA, Mehta SR, Peters R, et al. Clopidogrel in Unstable angina to prevent Recurrent ischemic Events Trial. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation. 2004; 110(10): 1202–1208.
  32. Gao Ge, Zheng Z, Pi Yi, et al. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial. J Am Coll Cardiol. 2010; 56(20): 1639–1643.
  33. Kulik A, Le May MR, Voisine P, et al. Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial. Circulation. 2010; 122(25): 2680–2687.
  34. Rafiq S, Johansson P, Kofoed K, et al. Thrombelastographic hypercoagulability and antiplatelet therapy after coronary artery bypass surgery (TEG-CABG trial): a randomized controlled trial. Platelets. 2017; 28(8): 786–793.
  35. Mannacio VA, Di Tommaso L, Antignan A, et al. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypaSS occlusion After off-pump procedures) randomised study. Heart. 2012; 98(23): 1710–1715.
  36. Kulik A, Ruel M, Jneid H, et al. American Heart Association Council on Cardiovascular Surgery and Anesthesia. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015; 131(10): 927–964.
  37. Wallentin L, Becker RC, Budaj A, et al. PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361(11): 1045–1057.
  38. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol. 2011; 57(6): 672–684.
  39. Brilakis ES, Held C, Meier B, et al. Effect of ticagrelor on the outcomes of patients with prior coronary artery bypass graft surgery: insights from the PLATelet inhibition and patient outcomes (PLATO) trial. Am Heart J. 2013; 166(3): 474–480.
  40. Schneider DJ. Mechanisms potentially contributing to the reduction in mortality associated with ticagrelor therapy. J Am Coll Cardiol. 2011; 57(6): 685–687.
  41. Schneider DJ, Chava S. Factors influencing platelet reactivity in patients undergoing coronary artery bypass surgery. Coron Artery Dis. 2016; 27(3): 185–190.
  42. Smith PK, Goodnough LT, Levy JH, et al. Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis. J Am Coll Cardiol. 2012; 60(5): 388–396.
  43. Saw J, Wong GC, Mayo J, et al. Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery. Heart. 2016; 102(10): 763–769.
  44. Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA. 2018; 319(16): 1677–1686.
  45. de Waha A, Sandner S, von Scheidt M, et al. A randomized, parallel group, double-blind study of ticagrelor compared with aspirin for prevention of vascular events in patients undergoing coronary artery bypass graft operation: Rationale and design of the Ticagrelor in CABG (TiCAB) trial: An Investigator-Initiated trial. Am Heart J. 2016; 179: 69–76.
  46. Kulik A, Abreu AM, Boronat V, et al. Impact of ticagrelor versus aspirin on graft patency after CABG: Rationale and design of the TARGET (ticagrelor antiplatelet therapy to reduce graft events and thrombosis) randomized controlled trial (NCT02053909). Contemp Clin Trials. 2018; 68: 45–51.
  47. Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006; 34: 1608–1616.
  48. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010; 304(14): 1559–1567.
  49. van Straten AH, Bekker MW, Soliman Hamad MA, et al. Transfusion of red blood cells: the impact on short-term and long-term survival after coronary artery bypass grafting, a ten-year follow-up. Interact Cardiovasc Thorac Surg. 2010; 10: 37–42.
  50. Kamel H, Johnston SC, Kirkham JC, et al. Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Circulation. 2012; 126(2): 207–212.
  51. Siller-Matula JM, Petre A, Delle-Karth G, et al. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2017; 6(8): 753–770.
  52. Tomšič A, Schotborgh MA, Manshanden JSJ, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with dual antiplatelet treatment. Eur J Cardiothorac Surg. 2016; 50(5): 849–856.
  53. Hansson EC, Jidéus L, Åberg B, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study. Eur Heart J. 2016; 37(2): 189–197.
  54. Gurbel PA, Bliden KP, Butler K, et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation. 2009; 120(25): 2577–2585.
  55. Badri M, Abdelbaky A, Li S, et al. Precatheterization Use of P2Y Inhibitors in Non-ST-Elevation Myocardial Infarction Patients Undergoing Early Cardiac Catheterization and In-Hospital Coronary Artery Bypass Grafting: Insights From the National Cardiovascular Data Registry. J Am Heart Assoc. 2017; 6(9).
  56. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2016; 152(5): 1243–1275.
  57. Feres F. OPTIMIZE Trial Investigators. Three vs Twelve Months of Dual Antiplatelet Therapy After Zotarolimus-Eluting Stents. JAMA. 2013; 310: 2510–2522.
  58. Kim BK, Hong MK, Shin DH, et al. RESET Investigators. A new strategy for discontinuation of dual antiplatelet therapy: the RESET Trial (REal Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation). J Am Coll Cardiol. 2012; 60(15): 1340–1348.
  59. Palmerini T, Benedetto U, Bacchi-Reggiani L, et al. Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials. Lancet. 2015; 385(9985): 2371–2382.
  60. Giustino G, Baber U, Sartori S, et al. Duration of dual antiplatelet therapy after drug-eluting stent implantation: a systematic review and meta-analysis of randomized controlled trials. J Am Coll Cardiol. 2015; 65(13): 1298–1310.
  61. Navarese EP, Andreotti F, Schulze V, et al. Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials. BMJ. 2015; 350: h1618.
  62. Verma S, Goodman SG, Mehta SR, et al. Should dual antiplatelet therapy be used in patients following coronary artery bypass surgery? A meta-analysis of randomized controlled trials. BMC Surg. 2015; 15: 112.

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

By "Via Medica sp. z o.o." sp.k., Świętokrzyska 73 street, 80–180 Gdańsk, Poland

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail: viamedica@viamedica.pl