Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry

Abstract

BackgroundInterruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD).MethodsAll 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered.ResultsIn-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications.ConclusionsPerioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.

Clinical outcomes associated with per‐operative discontinuation of aspirin in patients with coronary artery disease: A systematic review and meta‐analysis

“…After screening of articles, 80 full texts were assessed. Finally, six studies that met the inclusion criteria were included . The literature search strategy is highlighted by the PRISMA sheet (Fig.…”

THA and TKA in patients with cardiovascular disease: What makes the risk of perioperative bleeding?

“…10 12 /L) this difference remained insignifi cant (p = 0.481; odds ratio 1.52; CI = 0.47;4.9). The difference between bleeding complications in patients after THA compared to TKA was also insignificant (p = 0.375; odds ratio 2.0; CI = 0.55; 4.81), and after adjustment (signifi cant: age, general anaesthesia, thrombocytes > 300.10 12 /L, borderline insignifi cant: warfarin administration, smoking) this difference remained insignifi cant (p = 0.273; odds ratio 2.0; CI = 0.57; 7.13).…”

“…In their history, the patients had any of diseases as follows: ischaemic heart disease, atrial fi brillation, stroke, deep vein thrombosis in lower limbs, pulmonary embolism, or heart valve surgery. Our study was a subanalysis of the PRAGUE 14 Study (registered on www.ClinicalTrials.gov under the identifi er NCT01897220) with the total number of 1 200 enrolled patients followed in 2011-2013, undergoing any neurosurgery, or thoracic, abdominal, urological or orthopaedic surgery (10).…”

“…The hypotheses were tested by the regression analysis method both without and with adjustment for demonstrated risk factors (sex, age, height, weight, smoking, hypertension, chronic heart failure, percutaneous coronary intervention, warfarin versus warfarin discontinuation three or more days before the surgery, ASA score, general vs local anaesthesia, acute vs elective procedure, haemoglobin < 100 g/L, thrombocytes > 300. 10 12 /L, thrombocytes < 150.10 12 /L, creatinine > 100 mmol/L); statistical software Stata 13 was used.…”

Antithrombotic therapy of patients with atrial fibrillation discharged after major non-cardiac surgery. 1-year follow-up. Sub-analysis of PRAGUE 14 study

“…Data for this sub-analysis were drawn from the PRAGUE-14 study (its details have already been published [ 12 ]), whose population consisted of 1200 consecutive patients (age 74.2 ±10.2 years, women 42.7%), who underwent major non-cardiac surgery (37.4% acute, 61.4% elective) in a large university hospital between 2011–2013, and who also had at least one known cardiovascular disease. The registry protocol was approved by the Ethics Committee of the University Hospital Kralovske Vinohrady in Prague (Czech Republic).…”