Letters
to
the
Editor
Antiplatelet therapy suspension in patients
undergoingcoronarysurgeryforacutecoronary
syndrome:Ispoint-of-careguidedstrategy the
bestchoice?
IntheirrecentpublicationNagashimaandcolleaguesevaluated
theimpactofrecentexposuretodualantiplatelettherapy(DAPT)
with aspirin and oral adenosine diphosphate (ADP)-receptor
antagonists (clopidogrel or ticlopidine) before urgent coronary
artery bypass graft (CABG) on increased risk of bleeding
complicationsinJapanesepatientswithacutecoronarysyndromes
(ACS)[1].Wereadwithinterestthearticleandcongratulatethe
authorsonthisoriginalandtimelystudy.Theauthorsprocessed
130 consecutive patients with ACS divided into two groups
accordingtotheuseofantiplateletmedicationpriortosurgery:
30 patients with preoperative thienopyridine exposure within
5daysand100patientswithoutexposure.Allpatientscontinued
toreceiveaspirin100mg/dayuntilsurgery.Theyconcludedthat
preoperative DAPT increases the risk of CABG-related major
bleedinginJapanesepatientswithACSundergoingurgentCABG.
Theauthorsaretobecommendedfortakingtheinitiativeto
challengethecurrentguidelinesgiventhatnodataareavailableon
Japanesepatients[2].
In our randomized controlled study carried on Caucasian
patientsundergoingCABGforACSwhowerereceivingclopidogrel
aloneorinadditiontoaspirin,weshowedawideinterindividual
variabilityinrecoverytimeafterclopidogrelwithdrawal,alarge
range of individual responses to clopidogrel, and a synergistic
effectof aspirin plus clopidogrel in terms ofdegree of platelet
inhibition[3].Onthisbasis,inourrecentcase–controlstudywe
analyzed the possibility to guide the time of preoperative
clopidogreldiscontinuationusinganindividualizedpoint-of-care
platelet function measurement and we suggested a different,
individualized,approachthancurrentguidelinestodeterminethe
optimaltimeforCABGsurgery,especiallyinthosepatientswho
needurgentsurgery[4].
Ourresultsshowedthatmonitoringplateletfunctionprovided
anobjectiveguidelinetodeterminea flexibletimingofsurgery.
Thisindividualizedstrategy reducedthepostoperativebleeding
andtheconsumptionofbloodproductsinourexperience.Finally,
itisstrikingtonote,thatweidentifiedanumberofpatientswith
normalplateletfunctiondespiteanadequatedosageofclopidogrel
(clopidogrel resistant)and patients who had a fastrecovery of
platelet function after clopidogrel discontinuation (within 2–3
days). By contrast nearly 20% of patients displayed persistent
plateletinhibition and required from6 to 8 days forcomplete
recovery of platelet function after clopidogrel suspension. In
conclusion, as suggested by the 2011 Blood Conservation
Clinical Practice Guidelines from the Society of Thoracic
Surgeons/Society of Cardiovascular Anesthesiologists, the
point-of-careguidedpreoperative
administration/discontinua-tionforantiplateletagentcouldbeindicatedfortheindividual
approachtopatientswiththeaimtoreducebothbleedingand
adverseevents[5].
Sourcesoffunding
Ourresearchreceivednograntfromanyfundingagencyinthe
public,commercial,ornot-for-profitsectors.
Conflictsofinterest
Theauthorsdeclarethatthereisnoconflictofinterest.
References
[1]NagashimaZ,TsukaharaK,UchidaK,HibiK,KarubeN,EbinaT,ImotoK,Kimura K,UmemuraS.Impactofpreoperativedualantiplatelettherapyonbleeding complicationsinpatientswithacutecoronarysyndromeswhoundergourgent coronaryarterybypassgrafting.JCardiol2017;69:156–61.
[2]AmsterdamEA,WengerNK,BrindisRG,CaseyJrDE,GaniatsTG,HolmesJrDR, JaffeAS,JneidH,KellyRF,KontosMC,LevineGN,LiebsonPR,MukherjeeD, PetersonED,SabatineMS,etal.2014AHA/ACCguidelineforthemanagementof patientswithnon-ST-elevationacutecoronarysyndromes:areport ofthe AmericanCollege ofCardiology/AmericanHeartAssociationTaskForceon PracticeGuidelines.Circulation2014;130:e344–426.
[3]MannacioV,DiTommasoL,AntignanoA,DeAmicisV,VosaC.Aspirinplus clopidogrelforoptimalplateletinhibitionfollowingoff-pumpcoronaryartery bypasssurgery:resultsfromtheCRYSSA(preventionofCoronaryarterybypaSS occlusion After off-pump procedures) randomised study. Heart 2012;98: 1710–5.
[4]MannacioV, MeierP,Antignano A,DiTommasoL, De AmicisV,VosaC. Individualized strategy for clopidogrel suspension in patients undergoing off-pumpcoronarysurgeryforacutecoronarysyndrome:acase–controlstudy. JThoracCardiovascSurg2014;148:1299–306.
[5]FerrarisVA,BrownJR,DespotisGJ,HammonJW,ReeceTB,SahaSP,SongHK, CloughER.2011UpdatetotheSocietyofThoracicSurgeonsandtheSocietyof CardiovascularAnesthesiologistsbloodconservationclinicalpractice guide-lines.AnnThoracSurg2011;91:944–82.
VitoMannacio(MD)*
LuigiMannacio(MD)
DepartmentofCardiacSurgery,UniversityFedericoII,Schoolof
Medicine,Naples,Italy
JournalofCardiology70(2017)402–403
Keywords:
Plateletaggregationinhibitors Coronaryarterybypass Bleeding
ContentslistsavailableatScienceDirect
Journal
of
Cardiology
j our na l ho me pa g e : w ww . e l se v i e r . com / l oca t e / j j cc
AnitaAntignano(MD)
DepartmentofCardiology,AziendaOspedaliera
Santobono-Pausillipon,Naples,Italy
GiovanniB.Pinna(MD,PhD)
DepartmentofCardiacSurgery,UniversityFedericoII,Schoolof
Medicine,Naples,Italy
*Correspondingauthorat:ViaS.Domenico62,80127Naples,Italy
E-mailaddress:vitomannacio2@libero.it(V.Mannacio).
Received27December2016
Availableonline11April2017
http://dx.doi.org/10.1016/j.jjcc.2017.02.009
Authors’reply
We thankMannacio and colleaguesfor their interest in our
study [1]. We concluded that preoperative dual antiplatelet
therapyincreasedtheincidenceofcoronaryarterybypassgrafting
(CABG)-related major bleeding in Japanese patients withacute
coronarysyndromes(ACS)undergoingurgentCABG.Thetimingof
CABGshould bedetermined byweighing the ischemic risksof
delayingsurgeryagainstthebleedingrisks,especiallyinpatients
with increased risks of both fatal ischemic events and major
bleeding.
Itiswellknownthattheantiplateletresponsetoclopidogrel
widely varies among individuals. Mannacio and colleagues
reportedawideinter-individualvariabilityinrecoverytimeafter
clopidogrel withdrawal [2].Therefore, it seemsreasonable that
plateletfunctiontestingmaybeconsideredinshorteningthetime
windowtoCABGfollowingP2Y12inhibitordiscontinuation[3],as
suggestedbythe2015EuropeanSocietyofCardiologyguidelines
for the management of ACS in patients presenting without
persistent ST-segment elevation (class IIb recommendation)
[4].Unfortunately,wedidnotobtaindataontheplateletinhibitory
responsetoP2Y12inhibitorsasanoptionforguidinginterruption
oftreatment.However,westandbytheconclusionofMannacio
and colleagues.Patients on dualantiplatelet therapy shouldbe
carefullyevaluatedfortheriskofCABG-relatedbleeding,including
preoperativeplateletfunctiontestingifitisavailable.Prospective,
randomized,multicenterstudiesusingplateletfunctiontestingare
neededtodeterminetheoptimaltimingofCABG.
References
[1]NagashimaZ,TsukaharaK,UchidaK,HibiK,KarubeN,EbinaT,ImotoK,Kimura K,UmemuraS.Impactofpreoperativedualantiplatelettherapyonbleeding complicationsinpatientswithacutecoronarysyndromeswhoundergourgent coronaryarterybypassgrafting.JCardiol2017;69:156–61.
[2]MannacioVA,DiTommasoL,AntignanA,DeAmicisV,VosaC.Aspirinplus clopidogrelforoptimalplateletinhibitionfollowingoff-pumpcoronaryartery bypass surgery: results fromthe CRYSSA (preventionof CoronaryarteRY bypaSS occlusion After off-pump procedures) randomised study. Heart 2012;98:1710–5.
[3]Mannacio V,MeierP,Antignano A,DiTommaso L,De AmicisV,VosaC. Individualized strategy for clopidogrel suspension in patients undergoing off-pumpcoronarysurgeryforacutecoronarysyndrome:acase-controlstudy. JThoracCardiovascSurg2014;148:1299–306.
[4]RoffiM,PatronoC,ColletJP,MuellerC,ValgimigliM,AndreottiF,BaxJJ,Borger MA,BrotonsC,ChewDP,GencerB,HasenfussG,KjeldsenK,LancellottiP, LandmesserU,etal.2015ESCGuidelinesforthemanagementofacutecoronary syndromesinpatientspresentingwithoutpersistentST-segmentelevation: TaskForcefortheManagementofAcute CoronarySyndromesinPatients PresentingwithoutPersistentST-SegmentElevationoftheEuropeanSociety ofCardiology(ESC).EurHeartJ2016;37:267–315.
KengoTsukahara(MD)*
DivisionofCardiology,YokohamaCityUniversityMedicalCenter,4-57
Urafune-ChoMinami-KuYokohama,232-0024Japan
*Fax:+81452619162
E-mailaddress:k-tsuka@yokohama-cu.ac.jp(K.Tsukahara).
Received24February2017
Availableonline3April2017
http://dx.doi.org/10.1016/j.jjcc.2017.03.003
Keywords: Clopidogrel Bleeding
Plateletfunctiontesting
