BACKGROUND: 

Patients presenting with acute coronary syndrome are administered a P2Y₁₂ inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice.

METHODS: 

We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared.

RESULTS: 

There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% (P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19–2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44–1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60–2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22–1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients.

CONCLUSIONS: 

There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.

中文翻译：

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马里兰州冠状动脉旁路移植术术前双重抗血小板治疗和血小板功能检测的中心变化

背景： 

出现急性冠状动脉综合征的患者在冠状动脉导管插入术前给予 P2Y ₁₂抑制剂和阿司匹林，以防止血栓形成导致的进一步心肌损伤。指南建议患者接受双重抗血小板治疗 (DAPT) 和择期心脏手术之间的标准等待期。由于 25% 至 30% 的人群可能被认为对氯吡格雷无反应，因此血小板功能检测可用于确定手术时机和评估出血风险。尚未确定跨中心使用标准等待期或血小板功能测试的程度，这代表了标准化实践的重要机会。

方法： 

我们使用来自马里兰心脏手术质量倡议组织的数据，从 2011 年到 2020 年进行了一项回顾性队列研究，该组织由该州所有 10 家进行心脏手术的医院组成。医院在该时间段内检查了手术后 5 天内接受 DAPT 的患者比例。混合效应多变量逻辑回归用于检查术前 DAPT 与缺血和出血结果的关联。对中心是否使用术前血小板功能检测进行了调查，并对出血结果进行了比较。

结果： 

不同中心的术前 DAPT 使用存在显着异质性，从 2% 到 54% 不等（P < .001）。单独冠状动脉旁路移植术 (CABG) 后 5 天内的 DAPT 与更高的出血再手术几率相关（优势比 [OR]，1.55；95% 置信区间 [CI]，1.19–2.01；P = .001），>输注 2 个单位的红细胞 (RBC) (OR, 1.62; 95% CI, 1.44–1.81; P < .001)，输注 >2 个单位的非 RBCs (OR, 1.79; 95% CI, 1.60–2.00 ; P < .001)。在使用术前血小板功能检测来指导手术时机的 5 家医院中，5 天内进行 DAPT 的几率更大（OR，1.33；95% CI，1.22-1.45；P < .001），更少的红细胞 >2 单位输血（ 22% 对 33%；P < .001）和非红细胞 > 2 个单位（17% 对 28%；P < .001）在 DAPT 患者中的输血。

结论： 

不同医院中心在 CABG 后 5 天内 DAPT 的使用存在显着差异。术前血小板功能测试可以让接受 DAPT 的患者更早地进行手术，而不会增加出血风险。