Ray Joel G, Deniz Stacy, Olivieri Anthony, Pollex Erika, Vermeulen Marian J, Alexander Kurian S, Cain David J, Cybulsky Irene, Hamielec Cindy M
Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada.
BMC Cardiovasc Disord. 2003 May 22;3:3. doi: 10.1186/1471-2261-3-3.
The administration of antiplatelet drugs before coronary artery bypass graft surgery (CABG) is associated with an increased risk of major hemorrhage and related surgical reexploration. Little is known about the relative effect of combined clopidogrel and aspirin on blood product use around the time of CABG. We evaluated the associated risk between the combined use of aspirin and clopidogrel and the transfusion of blood products perioperatively.
We retrospectively studied a cohort of 659 individuals who underwent a first CABG, without concomitant valvular or aortic surgery, at a single large Canadian cardiac surgical centre between January 2000 and April 2002. The four study exposure groups were those prescribed aspirin (n = 105), clopidogrel (n = 11), the combination of both (n = 46), or neither drug (n = 497), within 7 days prior to CABG. The primary study outcome was the excessive transfusion of blood products during CABG and up to the second post-operative day, defined as > or = 2 units of packed red blood cells (PRBC), > or = 2 units of fresh frozen plasma, > or = 5 units of cryoprecipitate or > or = 5 units of platelets. Secondary outcomes included the mean number of transfused units of each type of blood product.
A greater mean number of units of PRBC were transfused among those who received clopidogrel alone (2.9) or in combination with aspirin (2.4), compared to those on aspirin alone (1.9) or neither antiplatelet drug (1.4) (P = 0.001). A similar trend was seen for the respective mean number of transfused units of platelets (3.6, 3.7, 1.3 and 1.0; P < 0.001) and fresh frozen plasma (2.5, 3.1, 2.3, 1.6; P = 0.01). Compared to non-users, the associated risk of excessive blood product transfusion was highest among recipients of aspirin and clopidogrel together (adjusted OR 2.2, 95% CI 1.1-4.3). No significant association was seen among lone users of aspirin (adjusted OR 1.0, 95% CI 0.6-1.6) or clopidogrel (adjusted OR 0.7, 95% CI 0.2-2.5), compared to non-users.
While combined use of aspirin and clopidogrel shortly before CABG surgery may increase the associated risk of excess transfusion of blood products perioperatively, several study limitations prevent any confident conclusions from being drawn. Beyond challenging these findings, future research might focus on the value of both intraoperative monitoring of platelet function, and the effectiveness of antifibrinolytic agents, at reducing the risk of postoperative bleeding.
冠状动脉旁路移植术（CABG）前使用抗血小板药物会增加大出血及相关手术再次探查的风险。关于氯吡格雷和阿司匹林联合使用对CABG围手术期血液制品使用的相对影响，目前知之甚少。我们评估了阿司匹林和氯吡格雷联合使用与围手术期血液制品输注之间的相关风险。
我们回顾性研究了2000年1月至2002年4月期间在加拿大一家大型心脏外科中心接受首次CABG且未同时进行瓣膜或主动脉手术的659例患者。四个研究暴露组分别为在CABG前7天内服用阿司匹林（n = 105）、氯吡格雷（n = 11）、两者联合使用（n = 46）或未服用任何一种药物（n = 497）的患者。主要研究结局是CABG期间及术后第二天内血液制品的过度输注，定义为≥2单位浓缩红细胞（PRBC）、≥2单位新鲜冰冻血浆、≥5单位冷沉淀或≥5单位血小板。次要结局包括每种血液制品的平均输注单位数。
与单独使用阿司匹林（1.9）或未使用任何抗血小板药物（1.4）的患者相比，单独使用氯吡格雷（2.9）或与阿司匹林联合使用（2.4）的患者输注的PRBC平均单位数更多（P = 0.001）。血小板（3.6、3.7、1.3和1.0；P < 0.001）和新鲜冰冻血浆（2.5、3.1、2.3、1.6；P = 0.01）的平均输注单位数也呈现类似趋势。与未使用者相比，阿司匹林和氯吡格雷联合使用者过度输注血液制品的相关风险最高（调整后OR 2.2，95% CI 1.1 - 4.3）。与未使用者相比，单独使用阿司匹林（调整后OR 1.0，95% CI 0.6 - 1.6）或氯吡格雷（调整后OR 0.7，95% CI 0.2 - 2.5）的使用者之间未发现显著关联。
虽然在CABG手术前不久联合使用阿司匹林和氯吡格雷可能会增加围手术期过度输注血液制品的相关风险，但由于本研究存在若干局限性，无法得出任何确凿结论。除了对这些发现提出质疑外，未来的研究可能会聚焦于术中血小板功能监测以及抗纤溶药物在降低术后出血风险方面的有效性。
