Interactive Cardiovascular and Thoracic Surgery 2:413-415(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Does aspirin 6 h after coronary artery bypass grafting optimise graft patency?
Ghassan Musleh and
Joel Dunning*
Department of Cardiothoracic Surgery, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
* Corresponding author. Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, USA. Tel./fax: +44-780-154-8122
joeldunning{at}doctors.org.uk
Received August 11, 2003;
received in revised form August 12, 2003;
accepted August 13, 2003
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether aspirin given 6 h after coronary arterial bypass grafting optimises graft patency. Altogether 201 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is good evidence that Aspirin given <6 h post surgery optimally reduces graft occlusion, without an increase in bleeding.
Key Words: Aspirin; Vascular patency; Evidence-based medicine; Thoracic surgery
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1. Clinical scenario
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You are asked to review a 65-year-old patient who had a coronary artery bypass grafting (CABG) 6 h ago. Preoperatively he had triple vessel disease and good ventricular function. 600 ml of blood has been recorded in the drain bottles and 40 ml drained in the last hour. The nurse asks you if the first dose of aspirin should be omitted. You are tempted to omit this first dose of aspirin but you wonder what implication this may have on the long-term patency of this man's grafts.
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2. Three-part question
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In [patients following coronary arterial bypass grafting] is [aspirin commenced 6-h post surgery compared to 24-h post surgery] the best treatment to [optimise graft patency].
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3. Search strategy
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Medline 1966-July 2003 using the OVID interface [exp coronary artery bypass/OR coronary art$ bypass.mp OR CABG.mp OR exp thoracic surgery/OR cardiopulmonary bypass.mp OR exp cardiovascular surgical procedures/OR exp thoracic surgical procedures/] AND [exp aspirin/OR aspirin.mp] AND [exp vascular patency/OR exp graft occlusion, vascular/OR exp graft survival/OR graft patency.mp] AND [maximally sensitive RCT filter].
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4. Search outcome
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Two hundred one papers were found of which six were deemed to be relevant. In addition the American Heart Association guideline for CABG surgery provided a recent systematic review and was added below [1–7]. These are summarised in Table 1.
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5. Results
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Fremes et al. in their Meta-analysis of 12 studies found that the benefit of Aspirin was optimal if given at 6 h. In the individual studies, Gavaghan showed the largest risk reduction, when aspirin was given at 1-h post operation, but there was a non-significant increased rate of re-operation in this group. The study by Sharma et al. showed that there was no benefit in giving aspirin if starting more than 48 h post-operatively No significant increases in post operative bleeding were shown in any studies.
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6. Clinical bottom line
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There is good evidence that aspirin given <6 h post surgery optimally reduces graft occlusion, without an increase in bleeding.
doi:10.1016/S1569-9293(03)00181-6
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References
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- Fremes SE, Levinton C, Naylor CD, Chen E, Goldman BS. Optimal antithrombotic therapy following aortocoronary bypass: a meta-analysis. Eur J Cardiothorac Surg. 1993;7:169–180[Abstract]
- Gavaghan TP, Gebski V, Baron DW. Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. A placebo-controlled, randomized study. Circulation. 1991;83:1526–1533[Abstract/Free Full Text]
- Sanz G. Does low-dose aspirin prevent aortocoronary vein bypass graft occlusion? The Spanish Group for Aortocoronary Bypass Follow-up (GESIC Study). Thromb Res. 1990;12:23–26[Medline]
- Chesebro JH, Fuster V, Elveback LR, Clements IP, Smith HC, Holmes DR Jr, Bardsley WT, Pluth JR, Wallace RB, Puga FJ. Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations. N Engl J Med. 1984;310:209–214[Abstract]
- Lorenz RL, Schacky CV, Weber M, Meister W, Kotzur J, Reichardt B, Theisen K, Weber PC. Improved aortocoronary bypass patency by low-dose aspirin (100 mg daily). Effects on platelet aggregation and thromboxane formation. Lancet. 1984;1:1261–1264[CrossRef][Medline]
- Sharma GV, Khuri SF, Josa M, Folland ED, Parisi AF. The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency. Circulation. 1983;68:II218–II221[Medline]
- Eagle KA, Guyton RA, Davidoff R. American college of cardiology guidelines for coronary artery bypass graft surgery. J Am Coll Cardiol. 1999;99:1262–1346
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Abstract
1. Clinical scenario