Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry

Abstract

Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.

Hospital Variability Drives Inconsistency in Antiplatelet Use After Coronary Bypass

“…Hospital-level variation is not a new observation and has been demonstrated by other multicenter groups in several areas including pre-CABG antiplatelet discontinuation and transfusion rates after cardiovascular procedures. [32][33][34] In our current study, inter-hospital consistency in the utilization of other guideline-directed medications, such as statins and aspirin, suggest that this is not indicative of a hospital quality gap, but rather a difference of perception as to the appropriateness of DAPT in post-CABG patients.…”

Ticagrelor and CABG for acute coronary syndrome?—It is complicated

“…The authors are commended for shedding some light on the real‐world approach to dealing with an issue that has become an everyday reality for cardiac surgeons, yet for which little evidence exists to guide optimal patient management. Although surveys of this nature are generally subject to reporting bias, the authors' findings very likely reflect current practice patterns in the United States and Europe 5 …”

“…Although surveys of this nature are generally subject to reporting bias, the authors' findings very likely reflect current practice patterns in the United States and Europe. 5 Studies on the long-term use of ticagrelor in patients with chronic coronary syndromes and prior MI 6 or type II diabetes mellitus 7 have shown a significant increase in major bleeding events, as may be expected in trials comparing a potent antiplatelet agent with a placebo. 8 However, bleeding risk is much more difficult to characterize in a surgical setting.…”

Supplemental Fibrinogen Restores Platelet Inhibitor-Induced Reduction in Thrombus Formation without Altering Platelet Function: An In Vitro Study

“…[29][30][31][32][33] In patients undergoing cardiac surgery during DAPT medication, available evidence demonstrates a graded association between the extent of P2Y 12 receptor inhibition and surgeryrelated bleeding, and suggests some efficacy of platelet transfusion. 4,[6][7][8][9] In contrast, in healthy volunteers autologous platelet transfusion revealed only minimal effects on platelet aggregation as assessed by light transmittance aggregometry and the VerifyNow-P2Y12 assay 24 and 48 hours after the last intake of ticagrelor. 10 A specific antigen-binding antidote for ticagrelor reversed ticagrelor antiplatelet effects in human PRP and in a mouse model.…”

“…5 Still, certain clinical conditions, such as ischemic, rhythmic, or hemodynamic instability may urge surgery, not allowing the optimal withdrawal period for P2Y 12 receptor inhibition and thereby increasing the risk of perioperative bleeding and mortality. 6 Although clinical studies in patients undergoing cardiac surgery suggest at least some efficacy of transfused platelets in reversing the effects of antiplatelet drugs, [7][8][9] autologous platelet transfusion administered in healthy volunteers 24 and 48 hours after the last intake of ticagrelor had only minimal effects on platelet reactivity. 10 In contrast, spiking blood of ticagrelor-treated patients with concentrated platelets from healthy volunteers in vitro improved platelet reactivity in a time-and concentrationdependent manner.…”