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Antiplatelet and antithrombotic therapy in patients referred for coronary artery bypass grafting

ESC Congress 2010

Acute Cardiac Care

This was a session that was jointly proposed by the Thrombosis and the Cardiovascular Surgery Working Groups covering a very important subject because of its daily practical implications in patients needing coronary surgical revascularisation.

The issue of “triple” therapy was addressed by Kurt Huber (Vienna) who stressed that in patients who need warfarin in top of aspirin and clopidogrel, DES should be avoided and INR should be maintained on the low side (2-2.5). Bleeding complications increase steeply if the INR is above 2.5. In patients who have received a BMS for an acute coronary syndrome, triple therapy is instituted for 4 weeks, followed by aspirin and wafarin up to 12 months and then warfarin for life. Under triple antithrombotic therapy, the bleeding risk increases slightly (from 2-3% to 4-6%). Independent predictors of increased bleeding are older age, diabetes, female gender, low weight and renal dysfunction.

Another important topic in this area is how to prevent premature discontinuation of antithrombotic therapy in view of the threefold increase in MACE rate within 10 days of aspirin or double antiplatelet (DAPT) discontinuation. For this to happen, clinicians should adequately inform patients and their doctors of the risks involved, avoid DES if a surgical procedure is planned, avoid DES if poor patient compliance is anticipated, and perform only indispensable surgical procedures during DAPT.

Adelino Leite Moreira (Porto) presented the management of pre CABG antiplatelet therapy which is one of the most important determinants of CABG outcome together with conduit choice. The issue centres around balancing the risks of bleeding complications and transfusion related complications against reduced ischemic events and improved graft patency. It is now recognised that low doses of aspirin (100-150mg) as opposed to high doses do not significantly increase the bleeding risk and may have a protective effect, reducing the risk of ischemic complications. Since the CURE study, aspirin plus clopidogrel has become a type IA recommendation for patients with NSTEMI ACS.

The issue of increased bleeding after CABG centres on the delay between clopidogrel suspension and surgery. Although Guidelines recommend a 5 day interval, recent studies suggest that maybe a 2-3 day interval would be enough to allow for a safe operation. There is wide inter patient variability in the degree of antiplatelet inhibition after DAPT and a bedside test that could assess the degree of platelet response would be helpful in the future to better define the optimal strategy.

Analysing the PLATO trial results in the CABG population, Freek Verheugt (Amsterdam) pointed out that it had shown no increase in bleeding complications and transfusion rates in the Ticagrelor arm. This novel potent antiplatelet agent has the advantage of being directly active without hepatic metabolism and, contrary to clopidogrel, is reversible and its effects disappear after 48 h.

Finally, I concentrated on peri-operative strategies to improve outcome in ACS patients undergoing CABG. Although surgery in the setting of acute STEMI has become the exception there are still patients with unfavourable anatomy for PCI and persistent ischemia that require urgent surgery. If the patient’s condition allows it, it is preferable to wait, stabilize the patient and operate after 3-4 days. If the patient is unstable or in cardiogenic shock, one has to avoid any delay and be prepared for some sort of support ranging from intra aortic balloon to a ventricular assist device. In NSTEMI, CABG is required in 10-15% of patients and the timing of the operation depends on a multidisciplinary discussion considering the clinical and anatomical conditions. Off pump CABG in experienced hands or CABG on the beating heart with cardiopulmonary bypass support may improve results of urgent surgical revascularisation in patients with ACS.




Antiplatelet and antithrombotic therapy in patients referred for coronary artery bypass grafting

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.