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Postoperative bleeding in coronary artery bypass patients on double antiplatelet therapy: predictive value of
Alessandro Della Corte1, Ciro Bancone1, Andrea Spadafora1
1Department of Cardiothoracic Sciences, Second University of Naples, Unit of Cardiac Surgery of the Monaldi Hospital, Naples, Italy.
Insights
Routine aggregometry testing can predict bleeding risk in patients undergoing coronary artery bypass grafting after double antiplatelet therapy. The adenosine diphosphate (ADP) test showed stronger correlation with blood loss in the acetylsalicylic acid plus ticagrelor group.
Area of Science:
- Cardiovascular Surgery
- Hematology
- Pharmacology
Background:
- Coronary artery bypass grafting (CABG) frequently involves preoperative double antiplatelet therapy (DAPT).
- Postoperative bleeding is a significant complication following CABG in patients on DAPT.
- Predictive markers for bleeding risk in this population are crucial for patient management.
Purpose of the Study:
- To evaluate the utility of routine aggregometry testing in predicting postoperative bleeding after CABG.
- To assess the impact of different DAPT regimens (aspirin plus clopidogrel vs. aspirin plus ticagrelor) and withdrawal durations on bleeding risk.
- To determine the correlation between aggregometry results and postoperative blood loss.
Main Methods:
- Prospective study of 226 patients undergoing on-pump isolated CABG.
- Preoperative Multiplate® analyzer aggregometry (adenosine diphosphate [ADP] and ASPI tests) performed immediately before surgery.
- Analysis of postoperative bleeding based on DAPT type, drug withdrawal duration, and aggregometry results using regression models.
Main Results:
- No significant difference in overall postoperative blood loss between aspirin plus clopidogrel (ASA+C) and aspirin plus ticagrelor (ASA+T) groups.
- Longer withdrawal intervals correlated with normalized ADP-related platelet function in both groups.
- The ADP test result independently predicted postoperative bleeding, with a stronger correlation observed in the ASA+T group.
Conclusions:
- Aggregometry, particularly the ADP test, is valuable in predicting postoperative bleeding in CABG patients on DAPT.
- The predictive value of aggregometry may differ based on the specific DAPT regimen used.
- Routine aggregometry can aid in risk stratification and management of bleeding complications post-CABG.
Objectives:
We tested the possible value of routine aggregometry testing for bleeding prediction following coronary artery bypass grafting in patients who received preoperative double antiplatelet therapy.
Methods:
In 226 patients undergoing on-pump isolated coronary artery bypass grafting, aggregometry [adenosine diphosphate (ADP) test and ASPI test] was always prospectively performed by Multiplate® analyser immediately before surgery. We assessed the differences in postoperative bleeding according to the type of double antiplatelet therapy [acetylsalicylic acid plus clopidogrel (ASA+C), or plus ticagrelor (ASA+T)], duration of clopidogrel/ticagrelor withdrawal (0-3 days or ≥ 4 days) and results of aggregometry tests. Multivariable predictors of blood losses were sought by linear regressions (drainage amount at 6, 12 and 24 postoperative hours) and logistic regression (increased bleeding: 75th percentile of blood losses at 6 h, i.e. >450 ml).
Results:
Overall, postoperative blood losses did not significantly differ between treatment groups (median at 6 h: ASA + C = 335 ml, ASA + T = 300 ml, P = 0.21). With longer withdrawal interval, higher rates of patients with normal ADP-related platelet function were observed in both groups (ASA + C: P = 0.04; ASA + T: P = 0.006) but only in the ASA + T group were blood losses significantly smaller at all 3 time points. Bleeders (>450 ml at 6 h) were significantly less frequent among patients with ADP test showing recovered platelet function (ASA + T: P = 0.002; ASA + C: P = 0.053). The correlation between ADP test result and blood losses amount was stronger in the ASA + T group (e.g. at 6 h: r = -0.6; P < 0.001). In multivariable analyses, the ADP test result independently predicted postoperative bleeding in the ASA + T group and the ASPI test in the ASA + C group.
Conclusions:
Aggregometry can help in predicting postoperative bleeding in double antiplatelet therapy patients undergoing coronary artery bypass grafting.
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