Postoperative Activity, but Not Preoperative Activity, of Antithrombin Is Associated with Major Adverse Cardiac Events After Coronary Artery Bypass Graft Surgery

Abstract

BACKGROUND Low levels of antithrombin (AT) have been independently associated with prolonged intensive care unit stay and an increased incidence of neurologic and thromboembolic events after cardiac surgery. We hypothesized that perioperative AT activity is independently associated with postoperative major adverse cardiac events (MACEs) in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS We prospectively studied 1403 patients undergoing primary CABG surgery with cardio-pulmonary bypass (CPB) (http://clinicaltrials.gov/show/NCT00281164). The primary clinical end point was occurrence of MACE, defined as a composite outcome of any one or more of the following: postoperative death, reoperation for coronary graft occlusion, myocardial infarction, stroke, pulmonary embolism, or cardiac arrest until first hospital discharge. Plasma AT activity was measured before surgery, after post-CPB protamine, and on postoperative days (PODs) 1–5. Multivariate logistic regression modeling was performed to estimate the independent effect of perioperative AT activity upon MACE. RESULTS MACE occurred in 146 patients (10.4%), consisting of postoperative mortality (n = 12), myocardial infarction (n = 108), stroke (n = 17), pulmonary embolism (n = 8), cardiac arrest (n = 16), or a subsequent postoperative or catheter-based treatment for graft occlusion (n = 6). AT activity at baseline did not differ between patients with (0.91 ± 0.13 IU/mL; n = 146) and without (0.92 ± 0.13 IU/mL; n = 1257) (P = 0.18) MACE. AT activity in both groups was markedly reduced immediately after CPB and recovered to baseline values over the ensuing 5 PODs. Postoperative AT activity was significantly lower in patients with MACE than those without MACE. After adjustment for clinical predictors of MACE, AT activity on PODs 2 and 3 was associated with MACE. CONCLUSIONS Preoperative AT activity is not associated with MACE after CABG surgery. MACE is independently associated with postoperative AT activity but only at time points occurring predominantly after the MACE.

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

“…The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses (Tables 1 and 2). 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84 Of the 16 RCTs identified,1...…”

Postoperative Costs Associated With Outcomes After Cardiac Surgery With Extracorporeal Circulation: Role of Antithrombin Levels

“…In 2 recent publications, no association between the levels of AT and surgical outcomes was found 29 or only at some points was postoperative AT activity associated with major adverse cardiac events. 13 In the present results, the analysis of the costs highlighted that hospitalization represented the major portion of the average postoperative cost per patient (Ͼ96% in relation to the cost of complications management). However, the data indicated that the total cost would be higher in a patient with low AT levels by approximately €4,800, mainly owing to the estimated longer hospital stay of those patients (approximately ϩ30%).…”

“…8 During these surgeries, the levels of AT activity decrease owing to consumption 9 and to hemodilution, 10 resulting in a deficient amount of this protein at the end of the procedure, 11,12 which has been associated with a worse clinical recovery after surgery. [13][14][15] Furthermore, in these studies, the patients with low levels of AT activity after CS remained in the ICU longer, with mechanical ventilation, and required more surgical re-explorations and blood transfusions. 14, 15 Paparella et al 14 showed that, after being admitted to the ICU, patients with AT activity levels Ͻ63.7% had a much greater incidence of adverse cardiac events, such as excessive bleeding, infections, stroke, acute renal failure, sepsis, and atrial fibrillation.…”

Stress repair mechanism activity explains inflammation and apoptosis

“…Brain, nerve, retina, ovary, placenta, lung, artery, and cervix tissues are rich in tissue factor and therefore especially vulnerable to both primary malignancy and metastasis [210,552,556,557,[598][599][600]. SRM activity thus explains the close association of malignancy with chronic disease, environmental stress, inflammation, elevated Factor VII and Factor VIII activity, increased blood viscosity and coagulability, accelerated atherosclerosis, and seemingly unrelated forms of malignancy [556][557][558]566,[601][602][603][604][605].…”