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The Efficacy and Safety of Perioperative Antiplatelet Therapy

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Abstract

Widespread adoption of the antiplatelet agents into everyday clinical practice has revolutionized contemporary care of the cardiovascular patient. Major adverse cardiovascular events including death, myocardial infarction, stroke, and recurrent angina have all been shown to be significantly decreased when these agents are employed in the treatment of coronary atherosclerosis, acute coronary syndromes, myocardial infarction, and in the setting of percutaneous coronary intervention. As a growing number of patients on antiplatelet therapy are undergoing various surgical procedures, the potential risks and benefits these drugs pose perioperatively will become increasingly important. Available data indicate that, when used appropriately, these drugs can be used safely prior to surgery. Efficacy in improving surgical outcomes and in preventing adverse cardiovascular events postoperatively has also been demonstrated. The purpose of this review is to examine the perioperative safety and efficacy of the most widely used antiplatelet agents: aspirin; the thienopyridine clopidogrel; and the glycoprotein (GP) IIb/IIIa inhibitors abciximab, eptifibatide, and tirofiban. This information, coupled with emerging platelet monitoring techniques, may help provide additional assistance to the clinician to manage therapy and guide appropriate timing of both cardiac and noncardiac surgery.

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References

  1. Website. Heart and Stroke Statistical Update. American Heart Association, 2001.

  2. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ2002;324:71–86.

    Google Scholar 

  3. O'Brien JR. Effect of salicylates on human platelets. Lancet1968;1:1431.

    Google Scholar 

  4. Zucker M, Rothwell K. Differential influences of salicylate compounds on platelet aggregation and serotonin release. Curr Ther Res1978;23:194–199.

    Google Scholar 

  5. Ridker PM, Manson JE, Gaziano JM, Buring JE, Hennekens CH. Low-dose aspirin therapy for chronic stable angina. A randomized, placebo-controlled clinical trial. Ann Intern Med1991;114:835–839.

    Google Scholar 

  6. Steering Committee of the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing physicians' health study. N Engl J Med1989;321:129–135.

    Google Scholar 

  7. Antiplatelet Trialists' Collaboration. Collaborative over-view of randomised trials of antiplatelet therapy—I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ1994;308:81–106.

    Google Scholar 

  8. ISIS-2 Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction. Lancet1988;2:349–360.

    Google Scholar 

  9. Patrono C, Ciabattoni G, Pinca E, et al. Low dose aspirin and inhibition of thromboxane B2 production in healthy subjects. Thromb Res1980;17:317–327.

    Google Scholar 

  10. Kitchen L, Erichson RB, Sideropoulos H. Effect of drug-induced platelet dysfunction on surgical bleeding. Am J Surg1982;143:215–217.

    Google Scholar 

  11. Watson CJE, Deane AM, Doyle PT, Bullock KN. Identifiable factors in post-prostatectomy haemorrhage: the role of aspirin. British Journal of Urology1990;66:85–87.

    Google Scholar 

  12. Lawrence C, Sakuntabhai A, Tiling-Grosse S. Effect of aspirin and nonsteroidal antiinflammatory drug therapy on bleeding complications in dermatologic surgical patients. Journal of the American Academy of Dermatology1994;31:988–992.

    Google Scholar 

  13. Ferraris VA, Swanson E. Aspirin usage and perioperative blood loss in patients undergoing unexpected operations. Surgery, Gynecology, and Obstetrics1983;156:439–442.

    Google Scholar 

  14. Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg1995;80:303–309.

    Google Scholar 

  15. Michelson EL, Morganroth J, Torosian M, MacVaugh III H. Relation of preoperative use of aspirin to increased mediastinal blood loss after coronary artery bypass graft surgery. The Journal of Thoracic and Cardiovascular Surgery1978;76:694–697.

    Google Scholar 

  16. Torosian M, Michelson EL, Morganroth J, MacVaugh H, 3rd. Aspirin-and coumadin-related bleeding after coronary-artery bypass graft surgery. Ann Intern Med1978;89:325–328.

    Google Scholar 

  17. Ferraris VA, Ferraris SP, Lough FC, Berry WR. Preoperative aspirin ingestion increases operative blood loss after coronary artery bypass grafting. Annals of Thoracic Surgery1988;45:71–74.

    Google Scholar 

  18. Sethi GK, Copeland JG, Goldman S, Moritz T, Zadina K, Henderson WG. Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. Department of Veterans affairs cooperative study on antiplatelet therapy. J Am Coll Cardiol1990;15:15–20.

    Google Scholar 

  19. Goldman S, Copeland J, Moritz T, et al. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a veterans administration cooperative study. Circulation1988;77:1324–1332.

    Google Scholar 

  20. Willard JE, Lange RA, Hillis LD. The use of aspirin in ischemic heart disease. N Engl J Med1992;327:175–181.

    Google Scholar 

  21. Gavaghan TP, Gebski V, Baron DW. Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. Circulation1991;83:1526–1533.

    Google Scholar 

  22. Goldman S, Copeland J, Moritz T, et al. Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a veterans administration cooperative study. Circulation1989;80:1190–1197.

    Google Scholar 

  23. Stein PD, Dalen JE, Goldman S, Theroux P. Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts. Chest2001;119:278S–282S.

    Google Scholar 

  24. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy—II: maintenance of vascular graft or arterial patency by antiplatelet therapy. BMJ1994;308:159–168.

    Google Scholar 

  25. Jackson MR, Clagett GP. Antithrombotic therapy in peripheral arterial occlusive disease. Chest2001;119:283S–299S.

    Google Scholar 

  26. Lindblad B, Persson NH, Takolander R, Bergqvist D. Does low-dose acetylsalicylic acid prevent stroke after carotid surgery? A double-blind, placebo-controlled randomized trial. Stroke1993;24:1125–1128.

    Google Scholar 

  27. Berger PB. Oral antiplatelet agents: aspirin, ticlopidine, clopidogrel, cilostazol, and the oral glycoprotein IIb/IIIa inhibitors. In: Topol E, Ed. Acute Coronary Syndromes, 2nd edn. New York: Marcel Dekker, 2001:453–497.

    Google Scholar 

  28. CAPRIE Steering Committee. A randomised, blinded trial of Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE). Lancet1996;348:1329–1339.

    Google Scholar 

  29. Bhatt DL, Bertrand ME, Berger PB, et al. Meta-analysis of randomized and registry comparisons of ticlopidine with clopidogrel after stenting. Journal of the American College of Cardiology2002;39:9–14.

    Google Scholar 

  30. Weber A-A, Braun M, Hohlfeld T, Schwippert B, Tschope D, Schror K. Recovery of platelet function after discontinuation of clopidogrel treatment in healthy volunteers. British Journal of Clinical Pharmacology2001;52:333–336.

    Google Scholar 

  31. Caliendo G, Bradbury K, Mehl B. Ticlopidine, bleeding, and surgery. Mt Sinai J Med1994;61:372–373.

    Google Scholar 

  32. Criado A, Juffe A, Carmona J, Otero C, Avello F. Ticlopidine as a hemorrhagic risk factor in coronary surgery. Drug Intell Clin Pharm1985;19:673–676.

    Google Scholar 

  33. Grubitzsch H, Wollert H-G, Eckel L. Emergency coronary artery bypass grafting: Does excessive preoperative anti-coagulation increase bleeding complications and transfusion requirements? Cardiovascular Surgery2001;9:510–516.

    Google Scholar 

  34. The CURE Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes with-out ST-segment elevation. The New England Journal of Medicine2001;345:494–502.

    Google Scholar 

  35. Yende S, Wunderink RG. Effect of clopidogrel on bleeding after coronary artery bypass surgery. Crit Care Med2001;29:2271–2275.

    Google Scholar 

  36. Chevigne M, David JL, Rigo P, Limet R. Effect of ticlopidine on saphenous vein bypass patency rates: a double-blind study. Ann Thorac Surg1984;37:371–378.

    Google Scholar 

  37. Limet R, David JL, Magotteaux P, Larock MP, Rigo P. Prevention of aorta-coronary bypass graft occlusion. Beneficial effect of ticlopidine on early and late patency rates of venous coronary bypass grafts: a double-blind study. J Thorac Cardiovasc Surg1987;94:773–783.

    Google Scholar 

  38. Becquemin JP. Effect of ticlopidine on the long-term patency of saphenous-vein bypass grafts in the legs. Etude de la Ticlopidine apres Pontage Femoro-Poplite and the Association Universitaire de Recherche en Chirurgie. N Engl J Med1997;337:1726–1731.

    Google Scholar 

  39. Bhatt DL, Chew DP, Hirsch AT, Ringleb PA, Hacke W, Topol EJ. Superiority of clopidogrel versus aspirin in patients with prior cardiac surgery. Circulation2001; 103:363–368.

    Google Scholar 

  40. Sreeram GM, Sharma AD, Slaughter TF. Platelet glyco-protein IIb/IIIa antagonists: perioperative implications. J Cardiothorac Vasc Anesth2001;15:237–240.

    Google Scholar 

  41. Patrono C, Coller B, Dalen JE, et al. Platelet-active drugs: the relationships among dose, effectiveness, and side effects. Chest2001;119:39S–63S.

    Google Scholar 

  42. Waters JH, Anthony DG, Gottlieb A, Sprung J. Bleeding in a patient receiving platelet aggregation inhibitors. Anesth Analg2001;93:878–882.

    Google Scholar 

  43. Gammie JS, Zenati M, Kormos RL, et al. Abciximab and excessive bleeding in patients undergoing emergency cardiac operations. Ann Thorac Surg1998;65:465–469.

    Google Scholar 

  44. Boehrer JD, Kereiakes DJ, Navetta FI, Califf RM, Topol EJ. Effects of profound platelet inhibition with c7E3 before coronary angioplasty on complications of coronary by-pass surgery. EPIC Investigators. Evaluation Prevention of Ischemic Complications. Am J Cardiol1994;74:1166–1170.

    Google Scholar 

  45. Juergens CP, Yeung AC, Oesterle SN. Routine platelet transfusion in patients undergoing emergency coronary bypass surgery after receiving abciximab. Am J Cardiol1997;80:74–75.

    Google Scholar 

  46. Lincoff AM, LeNarz LA, Despotis GJ, et al. Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve long-term out-come with abciximab GP IIb/IIIa blockade. Evaluation of platelet IIb/IIIa Inhibition in STENTing. Ann Thorac Surg2000;70:516–526.

    Google Scholar 

  47. Dyke CM, Bhatia D, Lorenz TJ, et al. Immediate coronary artery bypass surgery after platelet inhibition with eptifibatide: results from PURSUIT. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor suppression using integrelin therapy. Ann Thorac Surg2000;70:866–871; discussion 871- 872.

    Google Scholar 

  48. Genoni M, Zeller D, Bertel O, Maloigne M, Turina M. Tirofiban therapy does not increase the risk of hemorrhage after emergency coronary surgery. J Thorac Cardiovasc Surg2001;122:630–632.

    Google Scholar 

  49. Marso SP, Bhatt DL, Roe MT, et al. Enhanced efficacy of eptifibatide administration in patients with acute coronary syndrome requiring in-hospital coronary artery bypass grafting. PURSUIT Investigators. Circulation2000;102:2952–2958.

    Google Scholar 

  50. Barr E, Thornton AR, Sax FL, Snapinn SM, Theroux P. Benefit of tirofiban plus heparin therapy in unstable angina/non-Q-wave myocardial infarction patients is observed regardless of interventional treatment strategy. Circulation1998;98:I-504.

    Google Scholar 

  51. Suzuki Y, Hillyer P, Miyamoto S, et al. Integrilin prevents prolonged bleeding times after cardiopulmonary bypass. Ann Thorac Surg1998;66:373–381.

    Google Scholar 

  52. Steinhubl SR, Talley JD, Braden GA, et al. Point-of-care measured platelet inhibition correlates with a reduced risk of an adverse cardiac event after percutaneous coronary intervention: results of the GOLD (AU-Assessing Ultegra) multicenter study. Circulation2001;103:2572–2578.

    Google Scholar 

  53. Mukherjee D, Moliterno DJ. Bedside platelet monitoring. In: Topol E, Ed. Acute Coronary Syndromes. New York: Marcel Dekker, 2001:563–597.

    Google Scholar 

  54. Lorenz RL, Schacky CV, Weber M, et al. Improved aortocoronary bypass patency by low-dose aspirin (100 mg daily): effects on platelet aggregation and thromboxane formation. Lancet1984;1(8389):1261–1264.

    Google Scholar 

  55. Brown BG, Cukingnan RA, DeRouen T, et al. Improved graft patency in patients treated with platelet-inhibiting therapy after coronary bypass surgery. Circulation1985; 72(1):138–146.

    Google Scholar 

  56. Sharma GVRK, Khuri SF, Josa M, Folland ED, Parisi AF. The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency. Circulation1983;68: (Suppl II):II218–II222.

    Google Scholar 

  57. McEnany MT, Salzman EW, Mundth ED, et al. The effect of antithrombotic therapy on patency rates of saphenous vein coronary artery bypass grafts. J Thorac Cardiovasc Surg1982;83:81–89.

    Google Scholar 

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  1. Cleveland Clinic Foundation, 9500 Euclid Ave., Desk F25, Cleveland, Ohio, 44195, USA

    J. Christopher Merritt & Deepak L. Bhatt

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Merritt, J.C., Bhatt, D.L. The Efficacy and Safety of Perioperative Antiplatelet Therapy. J Thromb Thrombolysis 13, 97–103 (2002). https://doi.org/10.1023/A:1016298831074

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