Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery

Sousa-Uva M, Storey R, Huber K, et al; on behalf of ESC Working Group on Cardiovascular Surgery and ESC Working Group on Thrombosis
Eur Heart J. 2014 May 6

The ESC Working Group on Cardiovascular Surgery and ESC Working Group on Thrombosis has published an expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft (CABG) surgery.

The risk of bleeding complications and perioperative coronary events are strongly influenced by the management of antithrombotic therapy before and after the CABG procedure. As a result of use of new P2Y12 inhibitors and increased pre-CABG percutaneous coronary interventions (PCI) with drug eluting stents (DES) which require specific antiplatelet regimens, as well as developments in surgical techniques, the ESC Working Group considered it was time for an update. To this extent, evidence of peri-CABG recommendations on antithrombotic management was reviewed. Randomised trials are rare, thus most of the evidence derives from observational studies and expert consensus.

The paper discusses risks and benefits that need to be considered when administering preoperative antiplatelet therapy, including aspirin, dual antiplatelet therapy, clopidogrel, prasugrel and ticagrelor. Strategies for individual risk stratification of bleeding vs. ischaemia are also discussed, as well as how to determine whether bridging therapy is needed between treatment interruption and CABG.
Due to individual variations in response to clopidogrel, the time to recover normal platelet reactivity differs from person to person following cessation of clopidogrel. Level of platelet reactivity at the time of surgery has been shown to be predictive of the risk of CABG-related bleeding, thus monitoring platelet function is recommended. Options for bedside platelet function testing are given.

Finally, postoperative management options of antiplatelet therapy are considered, both single and dual antiplatelet therapy, based on the available trial evidence.
All steps discussed in this document should guide risk stratification for bleeding and recurrent ischaemic events, and decision making on temporary interruption of antiplatelet therapy and bridging strategies, the use of platelet function monitoring and blood sparing management strategies, to further improve clinical outcome in patients undergoing CABG surgery.

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