Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
J Am Coll Cardiol. 2021 Mar 16;77(10):1277-1286. doi: 10.1016/j.jacc.2021.01.015.
Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Approximately 10% to 15% of these patients will undergo coronary artery bypass graft (CABG) surgery for index events, and current guidelines recommend stopping clopidogrel at least 5 days before CABG. This waiting time has clinical and economic implications.
This study aimed to evaluate if a platelet reactivity-based strategy is noninferior to standard of care for 24-h post-CABG bleeding.
In this randomized, open label noninferiority trial, 190 patients admitted with ACS with indications for CABG and on aspirin and P2Y receptor inhibitors, were assigned to either control group, P2Y receptor inhibitor withdrawn 5 to 7 days before CABG, or intervention group, daily measurements of platelet reactivity by Multiplate analyzer (Roche Diagnostics GmbH, Vienna, Austria) with CABG planned the next working day after platelet reactivity normalization (pre-defined as ≥46 aggregation units).
Within the first 24 h of CABG, the median chest tube drainage was 350 ml (interquartile range [IQR]: 250 to 475 ml) and 350 ml (IQR: 255 to 500 ml) in the intervention and control groups, respectively (p for noninferiority <0.001). The median waiting period between the decision to undergo CABG and the procedure was 112 h (IQR: 66 to 142 h) and 136 h (IQR: 112 to 161 h) (p < 0.001), respectively. In the intention-to-treat analysis, a 6.4% decrease in the median in-hospital expenses was observed in the intervention group (p = 0.014), with 11.2% decrease in the analysis per protocol (p = 0.003).
A strategy based on platelet reactivity-guided is noninferior to the standard of care in patients with ACS awaiting CABG regarding peri-operative bleeding, significantly shortens the waiting time to CABG, and decreases hospital expenses. (Evaluation of Platelet Aggregability in the Release of CABG in Patients With ACS With DAPT; NCT02516267).
双联抗血小板治疗（DAPT）适用于急性冠脉综合征（ACS）患者。约有 10%至 15%的此类患者会因首发事件而行冠状动脉旁路移植术（CABG），目前的指南建议在 CABG 前至少 5 天停用氯吡格雷。这一等待时间具有临床和经济意义。
本研究旨在评估基于血小板反应性的策略是否不劣于 CABG 后 24 小时内的标准治疗方案用于预防出血。
这是一项随机、开放标签的非劣效性试验，190 例因 ACS 入院且需行 CABG 并接受阿司匹林和 P2Y 受体抑制剂治疗的患者被分配至对照组（CABG 前 5 至 7 天停用 P2Y 受体抑制剂）、干预组（CABG 安排在下一个工作日，前一天血小板反应性用 Multiplate 分析仪[罗氏诊断公司，奥地利维也纳]进行测量，血小板反应性正常[预定义为≥46 聚集单位]）。
在 CABG 后的前 24 小时内，干预组和对照组的中位胸腔引流管引流量分别为 350ml（四分位距[IQR]：250 至 475ml）和 350ml（IQR：255 至 500ml）（非劣效性 p<0.001）。从决定行 CABG 到手术的中位等待时间分别为 112h（IQR：66 至 142h）和 136h（IQR：112 至 161h）（p<0.001）。意向治疗分析中，干预组的中位住院费用降低了 6.4%（p=0.014），按方案分析则降低了 11.2%（p=0.003）。
对于等待 CABG 的 ACS 患者，基于血小板反应性指导的策略不劣于标准治疗方案，在围手术期出血方面，显著缩短了 CABG 的等待时间，并降低了住院费用。（DAPT 释放时评价 ACS 患者 CABG 中的血小板聚集能力；NCT02516267）
