Vuilliomenet Thierry, Gebhard Caroline, Bizzozero Chiara, Glauser Salome, Blum Steffen, Buser Andreas, Bolliger Daniel, Grapow Martin T R, Siegemund Martin
Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland.
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
Interact Cardiovasc Thorac Surg. 2019 May 1;28(5):665-673. doi: 10.1093/icvts/ivy330.
Our goal was to evaluate the impact of the discontinuation times of dual antiplatelet therapy with clopidogrel, prasugrel or ticagrelor on postoperative bleeding rates and the use of blood products in patients undergoing isolated urgent coronary artery bypass grafting (CABG).
We retrospectively analysed 334 patients with acute coronary syndrome undergoing urgent CABG at the University Hospital Basel. A total of 262 patients continued to take dual antiplatelet therapy during the surgery (72 received clopidogrel; 68, prasugrel; and 122, ticagrelor). They were stratified by the discontinuation time of dual antiplatelet therapy (<24 h, 24-48 h, 48-72 h and >72 h). Seventy-two patients taking acetylsalicylic acid (ASA) as monotherapy served as a comparison group.
Median postsurgical bleeding rates were significantly higher with ticagrelor if it was discontinued <24 h [1220 ml, interquartile range (IQR) 978-1520 ml; P < 0.001], 24-48 h (1200 ml, IQR 800-1550 ml; P < 0.001) and 48-72 h (1100 ml, IQR 845-1245 ml; P = 0.036) but not if discontinued >72 h (700 ml, IQR 520-825 ml; P = 0.22) and with prasugrel if discontinued <24 h (1320 ml, IQR 900-1950 ml; P < 0.001) but not if discontinued 24-48 h (1050 ml, IQR 638-1438 ml; P = 0.089) or >72 h (750 ml, IQR 488-1040; P = 0.63) compared to ASA monotherapy (800 ml, IQR 593-1043 ml). The postsurgical use of blood products compared to ASA monotherapy (0, IQR 0-2 units) was significantly higher with ticagrelor and prasugrel if discontinued <24 h (2.5 units, IQR 0-6; P < 0.001 and 2 units, IQR 1-6; P < 0.001, respectively).
Discontinuation of ticagrelor and prasugrel for more than 72 h before urgent CABG was not associated with higher bleeding rates compared to treatment with ASA monotherapy. In contrast, discontinuation for less than 24 h was associated with higher use of blood products. For ticagrelor, this study supports evidence and recent guidelines proposing a shorter discontinuation time of 3 days and raises the question of whether the same could be true for prasugrel.
我们的目标是评估停用氯吡格雷、普拉格雷或替格瑞洛双联抗血小板治疗的时间对接受孤立性急诊冠状动脉旁路移植术（CABG）患者术后出血率及血液制品使用情况的影响。
我们回顾性分析了巴塞尔大学医院334例接受急诊CABG的急性冠状动脉综合征患者。共有262例患者在手术期间继续接受双联抗血小板治疗（72例接受氯吡格雷；68例接受普拉格雷；122例接受替格瑞洛）。他们根据双联抗血小板治疗的停药时间分层（<24小时、24 - 48小时、48 - 72小时和>72小时）。72例仅服用阿司匹林（ASA）作为单一疗法的患者作为对照组。
与ASA单一疗法（800毫升，四分位数间距[IQR] 593 - 1043毫升）相比，替格瑞洛在停药<24小时（1220毫升，IQR 978 - 1520毫升；P < 0.001）、24 - 48小时（1200毫升，IQR 800 - 1550毫升；P < 0.001）和48 - 72小时（1100毫升，IQR 845 - 1245毫升；P = 0.036）时，术后出血率中位数显著更高，但停药>72小时（700毫升，IQR 520 - 825毫升；P = 0.22）时则不然；普拉格雷在停药<24小时（1320毫升，IQR 900 - 1950毫升；P < 0.001）时术后出血率中位数显著更高，但停药24 - 48小时（1050毫升，IQR 638 - 1438毫升；P = 0.089）或>72小时（750毫升，IQR 488 - 1040；P = 0.63）时则不然。与ASA单一疗法（0，IQR 0 - 2单位）相比，替格瑞洛和普拉格雷在停药<24小时时术后血液制品的使用显著更高（分别为2.5单位，IQR 0 - 6；P < 0.001和2单位，IQR 1 - 6；P < 0.001）。
与ASA单一疗法相比，急诊CABG前停用替格瑞洛和普拉格雷超过72小时与更高的出血率无关。相比之下，停药少于24小时与更高的血液制品使用相关。对于替格瑞洛，本研究支持了证据及最近提出3天较短停药时间的指南，并引发了普拉格雷是否也如此（较短停药时间）的问题。
