Eur J Cardiothorac Surg 2009;35:197. doi:10.1016/j.ejcts.2008.10.001
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
EACTS guideline on antiplatelet and anticoagulation management in cardiac surgery
Andrea Collia,*,
Carlos A. Mestresb
a Department of Cardiac Surgery, University Hospital Germans Trias i Pujols, Ctra. Canyet sn, 08916 Badalona (Barcelona), Spain
b Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
Received 27 August 2008;
accepted 2 October 2008.
* Corresponding author. Tel.: +34 687 203754. (Email: colli.andrea.bcn{at}gmail.com).
Key Words: Antiplatelet • Anticoagulation • Coronary artery bypass graft • Heart valve prostheses
In the July issue of the EJCTS, Dunning and co-workers published the EACTS guidelines on antiplatelet and anticoagulation management in cardiac surgery [1]. We have read with great interest these guidelines and we would like to underline a few points that we understand need further clarification.
- 1. The ACC/AHA guidelines 2006 recommend the addition of aspirin 75–100 mg once daily to therapeutic warfarin for all patients with mechanical heart valves and those patients with biological valves who have risk factors (Level of Class I, Evidence: B) [2]. The ACCP 2008 guidelines recommend the addition of ASA only in patients with mechanical valves and additional factors for thromboembolism (AF, hypercoagulable state or low ejection fraction) (grade 1B).
- 2. The EACTS guidelines recommend that aspirin should be given postoperatively to all patients with CABG to improve graft patency with a dosage of 150–325 mg. The recommendation given is not acceptable because the currently available evidence is not in favor of this high dosage. Lower dosage such as 75–100 mg has shown to be effective; the advantage of using 325 mg is not statistically demonstrated, so from a legal point of view also, the EACTS should maintain the possibility to recommend a lower dosage too, as rightly stated by the ACCP 2008 guidelines and previously by the ACC/AHA guidelines [3].
- 3. It is so far not acceptable that the guidelines give an indication on the use of clopidogrel for the prevention of vein graft occlusion based on a study that has not been yet published, as well as indicating the use of clopidogrel and aspirin for 9–12 months for patients having cardiac surgery for acute coronary syndrome. The CAPRIE [4] and CURE [5] studies were not originally designed to investigate this topic; in addition, there was lack of information about cardiac surgery procedures.
Although guidelines are not law, they are gaining greater legal value; therefore, it would be necessary to keep the recommendations not so strict in the case of weak evidence as it is the case.
References
- Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U, Nashef SAM, on behalf of the EACTS Audit and Guidelines Committee, Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardiothorac Surg 2008;34:73–92.
- Bonow RO, Carabello BA, Kanu C, de Jr. LA, Faxon DP, Freed, MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith Jr. SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, ACC/AHA Task Force, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography, Interventions, Society of Thoracic Surgeons ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2006;114:e84-e231.[Free Full Text]
- Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter Jr. AM, Lytle BW, Marlow RA, Nugent WC, Orszulak T, American College of Cardiology; American Heart Association ACC/AHA 2004 guideline updates for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004;110:e340-e343.[Free Full Text]
- A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996;348:1329–39.
- Fox KA, Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ, Yusuf S. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularisation for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation 2004;110:1202-1208.[Abstract/Free Full Text]
