Nardi Paolo, Pisano Calogera, Turturici Maria, Bertoldo Fabio, Maggio Vito Renato, Bassano Carlo, Buioni Dario, Scafuri Antonio, Altieri Claudia, Ruvolo Giovanni
Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy.
Kardiochir Torakochirurgia Pol. 2021 Sep;18(3):145-151. doi: 10.5114/kitp.2021.109407. Epub 2021 Oct 5.
Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications.
We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG).
Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3-4 days (group A, = 159), 48-72 hours or 2-3 days (group B, = 126), < 24 hours or 0-1 day (group C, = 24) prior to CABG.
Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) ( = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours ( < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; = 0.02) and group C (HR = 6.9; = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor ( = 0.002).
Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2-3 and > 3-4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.
双联抗血小板治疗可降低急性冠状动脉综合征患者心血管死亡、心肌梗死及缺血性不良事件复发的风险，但对于急需进行冠状动脉手术的患者，它会增加围手术期严重出血并发症的风险。
我们评估了基于阿司匹林联合氯吡格雷或替格瑞洛的双联抗血小板治疗（DAPT）对接受冠状动脉旁路移植术（CABG）患者产生的影响。
333例患者在接受CABG前，分别于停药>72小时或3 - 4天（A组，n = 159）、48 - 72小时或2 - 3天（B组，n = 126）、<24小时或0 - 1天（C组，n = 24）停用DAPT。
手术死亡率在A组为1.87%，B组为0.79%，C组无死亡。纵隔再次探查发生率在A组为1.25%即2例患者，B组为1.59%即2例患者，C组为8.33%即4例患者（P = 0.01）。C组术后6小时失血超过500 ml的发生率更高，且6小时和24小时胸腔引流管失血量显著更高（P < 0.01）。多因素分析显示，C组中正在服用替格瑞洛（HR = 42.4；P = 0.02）和C组（HR = 6.9；P = 0.04）是手术再次探查的唯一独立预测因素。在C组中，服用氯吡格雷的患者手术再次探查率为2.56%即1/39例，服用替格瑞洛的患者为33.3%即3/9例（P = 0.002）。
与分别在CABG前2 - 3天及>3 - 4天停药相比，持续双联抗血小板治疗至CABG前1天或24小时，出血并发症风险显著增加。大出血和手术再次探查与手术全因或出血相关死亡率增加无关。正如预期的那样，在短时间内服用替格瑞洛相比氯吡格雷会带来更高的出血并发症风险。
