Peri-operative platelet function testing: The potential for reducing ischaemic and bleeding risks
Received: 02 February 2011
Accepted after major revision: 14 March 2011
25 November 2017 (online)
The pivotal role of platelet activation and reactivity during atherothrombotic event occurrence associated with acute coronary syndromes (ACS) or percutaneous coronary interventions (PCI) is well established. Numerous translational research studies have established a threshold level of platelet reactivity during dual antiplatelet therapy above which a higher risk for ischaemic event occurrence has been observed. The clinical validity of these threshold values in reducing ischemic event occurrence with modified P2Y12 receptor therapy is currently under investigation in large-scale clinical trials. The association between on-treatment platelet reactivity measured by an ex vivo assay and the occurrence of bleeding events is less established. Currently, there is limited evidence of an association between platelet inhibition and coronary artery bypass grafting (CABG)- related bleeding in patients on clopidogrel therapy indicating that preoperative platelet function monitoring may guide both the timing of elective CABG and the administration of blood products in patients needing surgery. However, in the absence of a large-scale prospective clinical trial, routine platelet function monitoring and modification of timing of surgery based on platelet function monitoring are currently not recommended.
- 1 King 3rd S.B. et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008; 51: 172-209.
- 2 Patrono C. et al. American College of Chest Physicians. Antiplatelet drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 199S-233S.
- 3 Gurbel PA. et al. Platelet function monitoring in patients with coronary artery disease. J Am Coll Cardiol 2007; 50: 1822-1834.
- 4 Bonello L. et al. Working Group on High On-Treatment Platelet Reactivity. Consensus and future directions on the definition of high on-treatment platelet reactivity to adenosine diphosphate. J Am Coll Cardiol 2010; 56: 919-933.
- 5 Ferreiro JL. et al. Platelet function testing and risk of bleeding complications. Thromb Haemost 2010; 103: 1128-1135.
- 6 Cesari F. et al. Relationship between high platelet turnover and platelet function in high-risk patients with coronary artery disease on dual antiplatelet therapy. Thromb Haemost 2008; 99: 930-935.
- 7 Vicenzi MN. et al. Coronary artery stenting and non-cardiac surgery–a prospective outcome study. Br J Anaesth 2006; 96: 686-693.
- 8 Ebrahimi R. et al. Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol 2009; 53: 1965-1972.
- 9 Berger JS. et al. Impact of Clopidogrel in Patients With Acute Coronary Syndromes Requiring Coronary Artery Bypass Surgery: A Multicenter Analysis. J Am Coll Cardiol 2008; 52: 1693-1701.
- 10 Kaluza GL. et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000; 35: 1288-1294.
- 11 Berger PB. et al. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv 2010; 3: 920-927.
- 12 Eikelboom JW. et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006; 114: 774-782.
- 13 Rao SV. et al. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J 2007; 28: 1193-1204.
- 14 Hajjar LA. et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. J Am Med Assoc 2010; 304: 1559-1567.
- 15 Murphy GJ. et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116: 2544-2552.
- 16 Kulier A. et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007; 116: 471-479.
- 17 Kushner FG. et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 120: 2271-2306.
- 18 The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial, I. Effects of Clopidogrel in Addition to Aspirin in Patients with Acute Coronary Syndromes without ST-Segment Elevation. N Engl J Med 2001; 345: 494-502.
- 19 Wiviott SD. et al. Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med 2007; 357: 2001-2015.
- 20 Fox KA. et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation 2004; 110: 1202-1208.
- 21 Herman CR. et al. Clopidogrel increases blood transfusion and hemorrhagic complications in patients undergoing cardiac surgery. Ann Thorac Surg 2010; 89: 397-402.
- 22 Ascione R. et al. In-hospital patients exposed to clopidogrel before coronary artery bypass graft surgery: a word of caution. Ann Thorac Surg 2005; 79: 1210-1216.
- 23 Price MJ. et al. Onset and offset of platelet inhibition after high-dose clopidogrel loading and standard daily therapy measured by a point-of-care assay in healthy volunteers. Am J Cardiol. 2006; 98: 491-494.
- 24 Gurbel PA. et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation 2009; 120: 2577-2585.
- 25 Held C. et al. Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Surgery Results From the PLATO (Platelet Inhibition and Patient Outcomes) Trial. J Am Coll Cardiol 2011; 57: 672-684.
- 26 Fleisher LA. et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007; 116: 1971-1996.
- 27 Poldermans D. et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 2009; 22: 2769-2812.
- 28 Nuttall GA. et al. Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology 2008; 109: 588-595.
- 29 van Kuijk JP. et al. Timing of noncardiac surgery after coronary artery stenting with bare metal or drug-eluting stents. Am J Cardiol 2009; 104: 1229-1234.
- 30 Sibbing D. et al. Antiplatelet effects of clopidogrel and bleeding in patients undergoing coronary stent placement. J Thromb Haemost 2010; 8: 250-256.
- 31 Cuisset T. et al. Predictive value of post-treatment platelet reactivity for occurrence of post-discharge bleeding after non-ST elevation acute coronary syndrome. Shifting from antiplatelet resistance to bleeding risk assessment?. Euroln-tervention 2009; 5: 325-329.
- 32 Gurbel PA. et al. Adenosine diphosphate-induced platelet-fibrin clot strength: a new thrombelastographic indicator of long-term poststenting ischemic events. Am Heart J 2010; 160: 346-354.
- 33 Nuttall GA. et al. Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology. 2001; 94: 773-781.
- 34 Shore-Lesserson L. et al. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 1999; 88: 312-319.
- 35 Wasowicz M. et al. The incremental value of thrombelastography for prediction of excessive blood loss after cardiac surgery: an observational study. Anesth Analg 2010; 111: 331-338.
- 36 Chen L. et al. Clopidogrel and bleeding in patients undergoing elective coronary artery bypass grafting. J Thorac Cardiovasc Surg 2004; 128: 425-431.
- 37 Mahla E. et al. Time based strategy to reduce clopidogrel associated bleeding during CABG. Results from the TARGET CABG study. Presented at Clinical Science: Special reports. American College of Cardiology Meeting; 2010
- 38 Rinder CS. et al. Platelet activation and aggregation during cardiopulmonary bypass. Anesthesiology 1991; 75: 388-393.
- 39 Reece MJ. et al. Near-patient platelet function testing in patients undergoing coronary artery surgery: a pilot study. Anaesthesia 2011; 66: 97-103.
- 40 Kwak YL. et al. Clopidogrel responsiveness regardless of the discontinuation date predicts increased blood loss and transfusion requirement after off-pump coronary artery bypass graft surgery. J Am Coll Cardiol 2010; 56: 1994-2002.
- 41 Ranucci M. et al. Multiple electrode whole-blood aggregometry and bleeding in cardiac surgery patients receiving thienopyridines. Ann Thorac Surg 2011; 91: 123-129.
- 42 Writing Committee. et al. ACCF/AHA Clopidogrel Clinical Alert: Approaches to the FDA „Boxed Warning”: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the American Heart Association. Circulation 2010; 122: 537-557.