Dual-Antiplatelet Therapy Prior to Surgical Revascularization Due to NSTEMI

Background: Subendocardial acute myocardial infarction (NSTEMI) is a common manifestation of coronary artery disease. Current guidelines recommend interventional/surgical treatment according to chronic coronary artery disease as well as dual-antiplatelet therapy (DAPT) for 12 months. Using DAPT prior to surgical revascularization (CABG) is controversial, due to an unclear effect on the patient outcome and possible bleeding complications.

Method: We performed a retrospective, single-center, observational analysis. Over the course of five years (2016–2020), we identified 590 NSTEMI patients (mean age 67.6 ± 10.1 years, 20.3% female) requiring CABG. The study cohort was divided into two groups: group NSTEMI + DAPT (n = 195) and group NSTEMI − DAPT (n = 395).

Results: Group baseline characteristics were not statistically different, besides a higher BMI (28.3 vs. 27.3, p = 0.02) and a higher EuroSCORE II (7.1 ± 9.3 vs. 5.6 ± 7.2, p = 0.04) in group +DAPT. Patients in cardiogenic shock were evenly distributed (8.2 vs. 6.6%, p = 0.47). Time interval from onset of symptoms to surgery was longer in group +DAPT (38.3 ± 12.7 minutes, p < 0.01). Operative characteristics (including length of surgery, cross clamp time, number of anastomosis) showed no significant differences.

Major adverse events occurred significantly more frequently in the +DAPT-group (31.8%) as opposed to the -DAPT-group (19.7%, p < 0.01). Cerebrovascular accidents occurred more often in the +DAPT-group (4.6 vs. 1%, p = 0.01). There is a trend toward more necessity of dialysis (8.2 vs. 4.3%, p = 0.05) and a trend toward more re-exploration for bleeding in group +DAPT (4.6 vs. 2.0%, p = 0.08). Transfusions of platelets (p < 0.01), red blood cell concentrates (p < 0.01) and fresh frozen plasmas (p = 0.02) was more likely in group +DAPT. Furthermore, there is a trend toward longer ventilation time in group +DAPT (12.1 ±88.9 hours, p = 0.07). However, overall hospital mortality was comparable (+DAPT 7.3% vs. –DAPT 4.9%, p = 0.26).

Conclusion: Revascularization of patients with DAPT due to NSTEMI is associated with increased risk of bleeding and the necessity of transfusion of blood products. This probably translates into longer ventilation time. In-hospital mortality seems not to be affected significantly. Therefore, DAPT should be carefully evaluated in patients who are likely to undergo CABG.

Publication History

Article published online:
03 February 2022