Background
Identifying predictors of bleeding in patients before coronary artery bypass grafting
surgery is important, given the complications of bleeding and finite supply of blood.
Patient response to aspirin is heterogeneous and can be evaluated using point-of-care
platelet function tests. We postulated that patients who hyper-respond to aspirin
given preoperatively, as identified by VerifyNow® Aspirin assay (Accumetrics, Inc.,
San Diego, CA, USA), are at increased risk of bleeding and transfusion.
Methods
This prospective pilot study examined response to aspirin in patients undergoing coronary
artery bypass grafting surgery (n = 61) from 2009 to 2013. Patients with aspirin reaction
unit (ARU) values in the lower 50th percentile as identified by VerifyNow® assays were defined as aspirin hyper-responders.
The proportion of patients transfused and the median adjusted indexed drop in haemoglobin
were compared between aspirin hyper-responders and non-hyper-responders. Logistic
regression was performed to determine factors associated with increased risk of transfusion.
Results
Seventy per cent (70%) of aspirin hyper-responders were transfused perioperatively
compared with 39% of patients who did not hyper-respond, (OR 3.694, 95% CI 1.275–10.706,
p = 0.014). VerifyNow® Aspirin hyper-responders had a greater median adjusted indexed
drop in haemoglobin compared to non-hyper-responders (34.1 g/L versus 26.6 g/L respectively,
p = 0.032). Multivariate analysis also showed VerifyNow® Aspirin hyper-response to
be an independent predictor of transfusion (p = 0.016). Other variables such as age,
gender, body mass index, renal insufficiency, and cross clamp and bypass times were
not predictors of postoperative bleeding in this pilot cohort.
Conclusions
VerifyNow® Aspirin is able to preoperatively identify aspirin hyper-responders at
an increased risk of bleeding and subsequent transfusion in the context of coronary
artery bypass graft surgery.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Heart, Lung and CirculationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Management of acute coronary syndrome: achievements and goals still to pursue. Novel developments in diagnosis and treatment.J Intern Med. 2012; 271: 521-536
- European Resuscitation Council Guidelines for Resuscitation 2010 Section 5. Initial management of acute coronary syndromes.Resuscitation. 2010; 81: 1353-1363
- Aspirin and clopidogrel response variability: review of published data.Tex Heart Inst J. 2008; 35: 313-320
- Aspirin resistance: effect of clinical, biochemical and genetic factors.Pharmacol Ther. 2011; 130: 213-225
- Preoperative continuation of aspirin therapy may improve perioperative saphenous venous graft patency after off-pump coronary artery bypass grafting.Ann Thorac Surg. 2015; 99: 576-581
- Ultra-low dose aprotinin decreases transfusion requirements and is cost effective in coronary operations.Ann Thorac Surg. 2001; 71: 158-164
- Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552
- Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.JAMA. 2004; 292: 1555-1562
- Increased mortality, morbidity and cost associated with red blood cell transfusion after cardiac surgery.Curr Opin Cardiol. 2008; 23: 607-612
- Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery.Circulation. 2011; 123: 577-583
- Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982
- Strategies to preempt and reduce the use of blood products: an Australian perspective.Curr Opin Anaesthesiol. 2012; 25: 66-73
- Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium.Circulation. 2011; 123: 2736-2747
- The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery.Anesth Analg. 2009; 108: 1741-1746
- Patient blood management: a new paradigm for transfusion medicine?.ISBT Science Series. 2009; 4: 423-435
- Advances in platelet function testing assessing bleeding complications in patients with coronary artery disease.Platelets. 2012; 23: 537-551
- Aspirin resistance and adverse clinical events in patients with coronary artery disease.Am J Med. 2007; 120: 631-635
- Platelet function assays.Transfus Apher Sci. 2003; 28: 307-317
- A comparison of six major platelet function tests to determine the prevalence of aspirin resistance in patients with stable coronary artery disease.Eur Heart J. 2007; 28: 1702-1708
- The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part -1—coronary artery bypass grafting surgery.Ann Thorac Surg. 2009; 88: S2-S22
- ACC/ AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease.Circulation. 2016; 134: e123-e155
- update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations.Ann Thorac Surg. 2012; 2012: 1761-1781
- The effect of preioperative aspirin on bleeding, transfusion, myocardial infarction, and mortality in coronary artery bypass surgery: a systematic review of randomized and observational studies.Eur Heart J. 2008; 29: 1057-1071
- Stopping vs. continuing aspirin before coronary artery surgery (the ATACAS Investigators of the ANZCA Clinical Trials Network).N Engl J Med. 2016; 374: 728-737
- Aspirin before coronary artery surgery.N Engl J Med. 2016; 375: 90-92
- Platelet function point of care tests in post-bypass cardiac surgery: are they relevant?.Br J Anaesth. 2002; 89: 715-721
- Does platelet reactivity predict bleeding in patients needing urgent coronary artery bypass grafting during dual antiplatelet therapy?.Ann Thorac Surg. 2016; 102: 2010-2017
- Comparison of Multiplate and Verify Now platelet function test in predicting clinical outcome in patients with acute coronary syndromes.Thrombosis Res. 2017; 152: 14-19
- Platelet reactivity and clinical outcomes after coronary artery implantation of drug-eluting stents (ADAPT-DES): a prospective multicentre registry study.Lancet. 2013; 382: 614-623
- Platelet inhibition assessed with VerifyNow, flow cytometryand PlateletMapping in patients undergoing heart surgery.Thrombosis Res. 2009; 124: 572-577
- Optimal timing of clopidogrel discontinuation in Japanese patients: platelet aggregation test using the VerifyNow® system.Gen Thorac Cardiovasc Surg. 2015; 63: 601-606
- Utility of VerifyNow point-of-care identification of an aspirin effect prior to emergency cardiac surgery.Ann Clin Lab Sci. 2015; 45: 377-381
- Use of an objective tool to assess platelet inhibition prior to off-pump coronary surgery to reduce blood usage.J Invasive Cardiol. 2012; 24: 49-52
Article info
Publication history
Published online: April 13, 2019
Accepted:
March 19,
2019
Received in revised form:
March 1,
2019
Received:
March 4,
2018
Identification
Copyright
© 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
