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Preoperative dual antiplatelet therapy increases risk after urgent coronary bypass surgery: A Netherlands heart
Heleen J C L Apostel1, Maaike M Roefs2, Amon Heijne3
1Department of Anesthesia, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
Insights
Dual antiplatelet therapy before urgent coronary artery bypass grafting increases bleeding and mortality risks. Inconsistent practices highlight the need for standardized guidelines for managing patients with acute coronary syndrome undergoing surgery.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Clinical Research
Background:
- Dual antiplatelet therapy (DAPT) is standard post-acute coronary syndrome (ACS).
- Perioperative management of DAPT before urgent coronary artery bypass grafting (CABG) is controversial.
- Optimal antiplatelet strategies for ACS patients needing urgent CABG require clarification.
Purpose of the Study:
- To assess the impact of preoperative DAPT on surgical and postoperative outcomes.
- To evaluate outcomes in patients undergoing urgent CABG after ACS.
- To analyze the association between recent DAPT and outcomes in urgent CABG patients.
Main Methods:
- Retrospective cohort study of 6913 patients undergoing urgent isolated CABG within 90 days of ACS.
- Comparison of patients on DAPT (aspirin + P2Y12 inhibitor within 48 hours preoperatively) versus aspirin alone.
- Propensity score matching and multivariable logistic regression for confounding adjustment.
Main Results:
- Recent DAPT use was independently associated with increased perioperative bleeding complications.
- Higher rates of reintervention (OR, 1.78), transfusion (OR, 1.85), and surgical mortality (OR, 2.02) were observed with DAPT.
- Significant interhospital variation in DAPT use (12%-84%) indicated inconsistent practices.
Conclusions:
- Recent DAPT before urgent CABG significantly increases perioperative bleeding risk, transfusion needs, and mortality.
- Substantial variation in DAPT use across centers necessitates standardized, evidence-based guidelines.
- Optimizing antiplatelet management is crucial for high-risk ACS patients undergoing surgical revascularization.
Objective:
Dual antiplatelet therapy (DAPT) is standard care after acute coronary syndrome, but its perioperative management before urgent coronary artery bypass grafting (CABG) remains controversial. By using data from the Netherlands Heart Registration, a nationwide Dutch registry, we sought to assess the impact of recent preoperative DAPT on surgical and postoperative outcomes in patients undergoing urgent CABG after acute coronary syndrome.
Methods:
In this multicenter retrospective cohort study, 6913 patients undergoing urgent isolated CABG within 90 days of acute coronary syndrome were analyzed. Patients receiving DAPT (aspirin + P2Y12 inhibitor within 48 hours preoperatively) were compared with those on aspirin alone. Propensity score matching and multivariable logistic regression were used to adjust for confounding.
Results:
Recent DAPT use was independently associated with increased perioperative bleeding complications, including greater rates of reintervention (odds ratio [OR], 1.78), transfusion (OR, 1.85), and surgical mortality (OR, 2.02). Considerable interhospital variation in DAPT use (12%-84%) underscores inconsistent practices across Dutch cardiac surgery centers.
Conclusions:
Recent DAPT before urgent CABG is independently associated with significantly increased perioperative bleeding risk, transfusion requirements, and mortality. The substantial interhospital variation in DAPT use across Dutch cardiac surgery centers further underscores the need for standardized, evidence-based guidelines to optimize antiplatelet management in high-risk patients with coronary syndrome requiring surgical revascularization.
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