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Utility of Pre-operative P2Y12 Levels for Perioperative Bleeding Risk in Isolated Coronary Artery Bypass Surgery
Crystal Li1, Joshua L Leibowitz1, Justin Robinson1
1Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
Insights
Preoperative platelet reactivity testing using P2Y12 platelet reactivity unit (PRU) may not reliably predict bleeding complications after coronary artery bypass grafting (CABG) surgery. Patients with lower PRU levels received more platelet transfusions without increased bleeding risks.
Area of Science:
- Cardiovascular Surgery
- Hematology
- Pharmacology
Background:
- Coronary artery bypass grafting (CABG) is a common cardiac surgery.
- P2Y12 inhibitors are frequently used preoperatively.
- Predicting bleeding complications in CABG patients on P2Y12 inhibitors is clinically important.
Purpose of the Study:
- To investigate the clinical utility of preoperative P2Y12 platelet reactivity unit (PRU) measurement in predicting bleeding complications after isolated CABG surgery.
- To assess if PRU levels can guide transfusion strategies in CABG patients.
Main Methods:
- Retrospective review of 189 patients undergoing isolated CABG between 2017-2023.
- Patients were stratified by preoperative P2Y12 PRU levels (<200 vs. ≥200) and P2Y12 inhibitor type (clopidogrel or ticagrelor).
- Clinical data including intraoperative and postoperative transfusions, chest tube output, and re-exploration for bleeding were analyzed.
Main Results:
- Patients with PRU <200 received significantly more intraoperative platelet transfusions compared to those with PRU ≥200 (0.7 vs. 0.3 units, P=0.001).
- No significant differences were observed in intraoperative red blood cell/plasma transfusions, postoperative transfusions, 24-hour chest tube output, or re-exploration rates for bleeding between PRU groups.
- Bleeding complications and outcomes did not differ based on the pharmacologic agent used (clopidogrel vs. ticagrelor) within either PRU group.
Conclusions:
- Preoperative P2Y12 PRU assessment at a cutoff of 200 appears to have limited clinical utility in predicting bleeding complications in CABG patients.
- Lower PRU levels were associated with increased intraoperative platelet transfusion use, but not with other bleeding-related outcomes.
- Further research may be needed to identify optimal predictors of bleeding in this patient population.
Abstract:
A retrospective review of patients at a single institution who underwent isolated coronary artery bypass (CABG) surgery between 2017 and 2023 was conducted to investigate the clinical utility of pre-operatively measuring platelet inhibition as a predictor of bleeding complications, especially in the context of bypass surgery. Patients who underwent CABG procedure and were on P2Y12 inhibitors such as clopidogrel or ticagrelor preoperatively and had preoperative P2Y12 platelet reactivity unit (PRU) level measured. Patients were stratified by a PRU <200 or ≥200. In both groups, patients were divided into patients who took clopidogrel and patients who took ticagrelor. There were 189 patients included in the study. Patients with a PRU ≥200 were of similar age and comorbidities to those with a PRU <200, however, more were female. Both groups had a similar mean duration of days since last P2Y12 inhibitor dose prior to surgery. There were greater intraoperative platelet transfusions in the PRU <200 group (mean 0.7 vs 0.3 units, P = 0.001). Intraoperative red blood cell and plasma transfusion and postoperative transfusions, 24-hour chest tube output, and re-exploration for bleeding were similar between the groups. There were no differences in bleeding complications between pharmacologic agent in either group. Our findings suggest that preoperative assessment of P2Y12 PRU may have limited clinical utility at a cutoff of 200 in predicting bleeding in patients undergoing CABG. Patients with PRU <200 received higher rates of platelet transfusion, without differences in other blood products.
