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Interactive Cardiovascular and Thoracic Surgery 2:427-430(2003)
© 2003 European Association of Cardio-Thoracic Surgery

Best evidence topic - Cardiac general

What is the optimal dose of aspirin after discharge following coronary bypass surgery

Joel Dunninga,* and Satish Dasb

a Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
b Wythenshawe Hospital, South Moor Road, Manchester, UK

* Corresponding author. Tel.: +44-7801548122
joeldunning{at}doctors.org.uk

Received August 28, 2003; accepted August 30, 2003


   Abstract
Top
 Abstract
1. Three-part question
 References
 
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, what is the optimal dose of aspirin post cardiac surgery that should be given to prevent graft occlusion and prolong survival. Altogether, 114 papers were found from Medline and 59 papers were found from the Cochrane Central Register of Controlled Trials 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 best evidence suggests that 325 mg optimally improves vein graft survival and mortality, and does not cause an increase in complications compared to lower doses.

Key Words: Evidence-based medicine; Thoracic surgery; Aspirin


   1. Three-part question
Top
 Abstract
 1. Three-part question
References
 
In [patients following coronary arterial bypass graft] what is the optimal dose of [aspirin] required to [prolonging event free survival]

1.1. Clinical scenario

You are ready to discharge a 57-year-old gentleman who has undergone CABG 8 days ago. It is your consultant's policy to discharge all people without contraindications on low dose aspirin, but you have recently attended a structured critical appraisal journal club and wonder whether a higher dose of aspirin may confer a survival advantage to your patient.

1.2. Search strategy

Medline 1966–Aug 2003 using the OVID interface ([exp Coronary Artery Bypass OR coronary artery bypass.mp OR vascular graft.mp] AND [exp aspirin OR aspirin.mp] AND [exp graft occlusion, vascular OR graft occlusion.mp OR vascular patency.mp] AND [maximally sensitive randomised control trial filter]) This search was repeated in the Cochrane Central Register of Controlled Trials.

1.3. Search outcome

One hundred and fourteen abstracts were found from medline and 59 papers from the Cochrane Central Register of Controlled Trials. Two meta-analyses were found from 1993/1994, which included all relevant studies pre-1991. Of the remaining papers, 104 were either irrelevant or of insufficient quality for inclusion and four further papers were relevant. The four papers and the two meta-analyses are shown in the table. The Journal Club also suggested one additional recent paper that had not yet been indexed by Medline, which is also included in the table [1–7]. The papers are presented in Table 1.


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  		Table 1 Summary of best evidence papers

 
1.4. Comment(s)

Fremes’ meta-analysis demonstrated a significant benefit of low and medium dose aspirin in comparison to high dose aspirin. The benefit of medium dose aspirin was greatest but confidence intervals cross the confidence intervals for low dose aspirin. Neither the anti-platelet trialists or the veterans study group were able to convincingly demonstrate an advantage of medium dose aspirin in comparison to low dose aspirin. Mangano et al. provide the first evidence for a convincing mortality benefit from aspirin. However, the range of aspirin used was from 80 to 650 mg, so no evidence was provided for choosing a dose within this range. Of note they also found a higher rate of GI and bleeding complications in the non-aspirin group.

These findings have all been supported by the ACCP Consensus Conference on Antithrombotic Therapy. They recommend 325 mg/day as the current best evidence recommendation for aspirin post cardiac surgery.

1.5. Clinical bottom line

Best evidence suggests that 325 mg optimally improves vein graft survival and mortality, and does not cause an increase in complications compared to lower doses.

doi:10.1016/S1569-9293(03)00202-0


   References
Top
 Abstract
 1. Three-part question
 References
 

  1. Fremes SE, Levinton C, Naylor CD, Chen E, Christakis GT, Goldman BS. Optimal antithrombotic therapy following aortocoronary bypass: a meta-analysis. Eur J Cardiothorac Surg. 1993;7:169–180[Abstract]
  2. Collaborative overview of randomised trials of antiplatelet therapy—II: Maintenance of vascular graft or arterial patency by antiplatelet therapy. Antiplatelet Trialists’ Collaboration [see comments]. [Review] [95 refs]. Br Med J 1994;308:159–168.
  3. Goldman S, Zadina K, Krasnicka B, Moritz T, Sethi G, Copeland J, Ovitt T, Henderson W. Predictors of graft patency 3 years after coronary artery bypass graft surgery. Department of Veterans Affairs Cooperative Study Group No. 297. J Am Coll Cardiol. 1997;29:1563–1568[Abstract]
  4. Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Kern KB, Sethi G, Sharma GV, Khuri S. Internal mammary artery and saphenous vein graft patency. Effects of aspirin. Circulation. 1990;82:IV237–IV242[Medline]
  5. Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y. Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study. Circulation. 1989;80:1190–1197[Abstract/Free Full Text]
  6. Stein P, Dalen J, Goldman S, Theroux P. Antithrombotic therapy in patients with saphenous veins and internal mammary arterybypass grafts. Chest. 2001;119:278S–282S[Free Full Text]
  7. Mangano DT. Aspirin and mortality from coronary bypass surgery. New Engl J Med. 2002;347:1309–1317[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
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Right arrow Email this article to a friend
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Right arrow Author home page(s):
Joel Dunning
Satish Das
Right arrow Permission Requests
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Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dunning, J.
Right arrow Articles by Das, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dunning, J.
Right arrow Articles by Das, S.
Related Collections
Right arrow Cardiac - pharmacology

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