Antiplatelet therapy with CABG: chaos in the Netherlands
Neth Heart J
Antiplatelet therapy with CABG: chaos in the Netherlands
F. W. A. Verheugt 0 1
0 Department of Cardiology, Onze Lieve Vrouwe Gasthuis , Amsterdam , The Netherlands
1 F. W. A. Verheugt
The original version of this article was revised because Table 1 was displayed incorrectly.
Published online: 13 July 2017
© The Author(s) 2017. This article is an open access publication. Corrected publication August 2017.
One of the factors affecting the fate of arterial and venous
bypass grafts in coronary artery bypass grafting (CABG)
is optimal antithrombotic protection. Traditionally,
antiplatelet therapy is the treatment of choice to protect grafts
against occlusion [
]. Oral anticoagulants have shown to
be effective as well [
], but not superior to antiplatelet
]. Therefore, aspirin has become the standard of
care in the prevention of graft occlusion [
a complicating factor is the use of dual antiplatelet therapy
(DAPT) with aspirin and a P2Y12 blocker (clopidogrel,
prasugrel or ticagrelor) in patients who have recovered
from acute coronary syndromes (ACS) [
]. Not only do
they have to undergo CABG for their index ACS, they may
already be on DAPT when they become eligible for CABG.
These considerations make the choice for antithrombotic
protection in patients undergoing CABG complex.
In this issue of the Netherlands Heart Journal, Janssen
et al. present the results of a survey amongst the
cardiothoracic centres in the Netherlands on their strategies of
perioperative antithrombotic therapy in CABG in the Netherlands
]. The bottom line is that there is a large variation in the
use of antithrombotic therapy around CABG, which was
quite similar to the situation 27 years ago [
they show the results of a registry in their own centre which
actually confirmed the disturbing findings in the rest of the
country. The authors correctly conclude that this is due to
the lack of stringent guidelines on antiplatelet therapy in
the field of coronary surgery.
With regards to preoperative aspirin, the majority of
centres discontinue aspirin, which is not unanimously advised
by the international guidelines (see below). In ACS patients
P2Y12 blockers are discontinued between 4 and 7 days
preoperatively in most centres, as mandated by the guidelines.
Astonishingly, the majority of centres (including the
reporting one) do not restart P2Y12 blockers after surgery in ACS
patients. This is against the guidelines, because the benefit
of restarting was already shown in CURE, the mother of all
ACS trials on P2Y12 blockers [
There are few guidelines on the perioperative
management of platelet inhibition in CABG. The most specific
guideline from Europe [
] dates from 2008, and the
American one is from 2014 [
]. The 2014 guideline issued by the
European Association for Cardio-Thoracic Surgery [
not clear on this issue and focusses more on percutaneous
revascularisation than CABG. A simplified
recommendation for antiplatelet management in CABG is distilled from
these guidelines and is given in Tab. 1.
In conclusion, even in 2017 there is little consensus on
antiplatelet strategies around CABG in the Netherlands.
This is probably due to the rather vague international
guidelines, which is a consequence of a relative paucity of
evidence from randomised clinical trials. Because of the good
results of cardiac surgery in the Netherlands, cardiothoracic
centres should continue to follow their own clinical practice
in the antiplatelet management in CABG.
Conflict of interest F. W. A. Verheugt has received honoraria for
consulting and presentations from AstraZeneca, Eli Lilly and
n.a. not applicable
aUnless expected high perioperative bleeding risk
bUnless continued clinical instability
cDuration depending on stent type and patient characteristics
dDuration at least 1 year after index ACS
with recent stent(s)
Stop 5–7 days (IIA)
Day 1 restart (IIA)c
with or without stent(s)
Stop 5–7 days (IIA)b
Day 1 restart (IIB)d
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