Safety of Early Coronary Surgery in Antiplatelet Non-Responders: A Retrospective Cohort Study

Dual antiplatelet therapy (DAPT) is frequently prescribed to patients with acute coronary syndromes on presentation. If these patients require inpatient surgical revascularisation, current guidelines suggest they await several days' DAPT washout prior to proceeding to operation. However, the rate of non-response to DAPT is significant, and there is minimal research available to assess if patients who are non-responders can safely proceed to surgery without waiting for washout.

A retrospective cohort study of prospectively collected data was undertaken, examining patients who proceeded to surgery before the guideline-recommended washout time compared to those with no DAPT exposure.

One hundred patients had Thromboelastogram (TEG) assessment of response to DAPT. There was a high rate of DAPT non- and low-response, 56% (n=56). Thirty-five non- and low-response patients proceeded to theatre prior to the guideline-recommended waiting time following DAPT. There was no statistically significant increase in bleeding or transfusion requirements (any transfusion, p=0.79), and no difference in morbidity and mortality (p=0.46). Non-responders proceeding early to surgery had a significantly shorter length of stay - non-responder 8.8±3.3 vs no DAPT 10.7±4.7 vs awaited washout 12.1±4.7 days (p<0.01).

There is a high rate of non-/low-response to DAPT, particularly clopidogrel. Non-responder patients do not have significant increase in overall morbidity and mortality, bleeding outcomes or transfusion requirements, and have the advantage of a significantly shorter length of hospital stay.