Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

This chapter about prevention of coronary artery bypass occlusion is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients undergoing coronary artery bypass grafting (CABG), we recommend aspirin, 75 to 162 mg/d, starting 6 h after operation over preoperative aspirin (Grade 1A). In patients in whom postoperative bleeding prevents the administration of aspirin at 6 h after CABG, we recommend starting aspirin as soon as possible thereafter (Grade 1C). For patients undergoing CABG, we recommend against addition of dipyridamole to aspirin therapy (Grade 1A). For patients with coronary artery disease undergoing CABG who are allergic to aspirin, we recommend clopidogrel, 300 mg, as a loading dose 6 h after operation followed by 75 mg/d p.o. (Grade 1C+). In patients who undergo CABG for non-ST-segment elevation acute coronary syndrome (ACS), we recommend clopidogrel, 75 mg/d for 9 to 12 months following the procedure in addition to treatment with aspirin (Grade 1A). For patients who have received clopidogrel for ACS and are scheduled for CABG, we recommend discontinuing clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). For patients undergoing CABG who have no other indication for vitamin K antagonists (VKAs), we suggest clinicians to not administer VKAs (Grade 2B). For patients undergoing CABG in whom oral anticoagulants are indicated, such as those with heart valve replacement, we suggest clinicians administer VKA in addition to aspirin (Grade 2C). For all patients with coronary artery disease who undergo internal mammary artery (IMA) bypass grafting, we recommend aspirin, 75 to 162 mg/d, indefinitely (Grade 1A). For all patients undergoing IMA bypass grafting without other indication for VKA, we suggest clinicians not use VKA (Grade 2C).

[1]  G. Guyatt,et al.  Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. , 2004, Chest.

[2]  S. Yusuf,et al.  Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. , 2001, The New England journal of medicine.

[3]  Deepak L. Bhatt,et al.  Superiority of Clopidogrel Versus Aspirin in Patients With Prior Cardiac Surgery , 2001, Circulation.

[4]  M. Feldman,et al.  Thrombotic thrombocytopenic purpura associated with ticlopidine in the setting of coronary artery stents and stroke prevention. , 1999, Archives of internal medicine.

[5]  J. Moses,et al.  Effectiveness of clopidogrel and aspirin versus ticlopidine and aspirin in preventing stent thrombosis after coronary stent implantation. , 1999, Circulation.

[6]  V. Fuster,et al.  Platelet-active drugs: the relationships among dose, effectiveness, and side effects. , 2004, Chest.

[7]  Thomas E. Moritz,et al.  Predictors of graft patency 3 years after coronary artery bypass graft surgery. Department of Veterans Affairs Cooperative Study Group No. 297. , 1997, Journal of the American College of Cardiology.

[8]  Post Coronary Artery Bypass Graft Trial Investigators The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation on obstructive changes in saphenous-vein coronary-artery bypass grafts. , 1997, The New England journal of medicine.

[9]  D. Clement A randomised, blinded, trial of Clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE) , 1996 .

[10]  P. Stein,et al.  Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts. , 1995, Chest.

[11]  M. Pfisterer,et al.  A comparison of internal mammary artery and saphenous vein grafts after coronary artery bypass surgery. No difference in 1-year occlusion rates and clinical outcome. CABADAS Research Group of the Interuniversity Cardiology Institute of The Netherlands. , 1994, Circulation.

[12]  D. Beton,et al.  Effects of antiplatelet therapy with indobufen or aspirin-dipyridamole on graft patency one year after coronary artery bypass grafting. , 1994, The Journal of thoracic and cardiovascular surgery.

[13]  Thomas E. Moritz,et al.  Long-term graft patency (3 years) after coronary artery surgery. Effects of aspirin: results of a VA Cooperative study. , 1994, Circulation.

[14]  E. Marubini,et al.  Factors Influencing 1‐Year Patency of Coronary Artery Saphenous Vein Grafts , 1993, Circulation.

[15]  B. Hockings,et al.  Placebo‐controlled trial of enteric coated aspirin in coronary bypass graft patients , 1993, The Medical journal of Australia.

[16]  M. Pfisterer,et al.  Prevention of one-year vein-graft occlusion after aortocoronary- bypass surgery: a comparison of low-dose aspirin, low-dose aspirin plus dipyridamole, and oral anticoagulants , 1993, The Lancet.

[17]  M. Konerding,et al.  Endothelial damage of the venous graft in CABG. Influence of solutions used for storage and rinsing on endothelial function. , 1993, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[18]  J. Neutze,et al.  The role of dipyridamole in addition to low dose aspirin in the prevention of occlusion of coronary artery bypass grafts. , 1992, Australian and New Zealand journal of medicine.

[19]  H. Huikuri,et al.  Efficacy and safety of anticoagulant therapy started pre-operatively in preventing coronary vein graft occlusion. , 1992, European heart journal.

[20]  J. Copeland,et al.  Starting Aspirin Therapy After Operation: Effects on Early Graft Patency , 1991, Circulation.

[21]  V. Gebski,et al.  Immediate Postoperative Aspirin Improves Vein Graft Patency Early and Late After Coronary Artery Bypass Graft Surgery: A Placebo‐Controlled, Randomized Study , 1991, Circulation.

[22]  O. Alfieri,et al.  INDOBUFEN VERSUS ASPIRIN PLUS DIPYRIDAMOLE AFTER CORONARY-ARTERY BYPASS-SURGERY , 1991 .

[23]  J. Hasford,et al.  Low-dose aspirin versus anticoagulants for prevention of coronary graft occlusion. , 1990, The American journal of cardiology.

[24]  G. Sanz,et al.  Prevention of early aortocoronary bypass occlusion by low-dose aspirin and dipyridamole. Grupo Español para el Seguimiento del Injerto Coronario (GESIC) , 1990, Circulation.

[25]  U. Brodin,et al.  Effect of dipyridamole (Persantin) on blood flow and patency of aortocoronary vein bypass grafts. , 1990, Scandinavian journal of thoracic and cardiovascular surgery.

[26]  Thomas E. Moritz,et al.  Internal mammary artery and saphenous vein graft patency. Effects of aspirin. , 1990, Circulation.

[27]  J. Copeland,et al.  Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study. , 1989, Circulation.

[28]  M. Pfisterer,et al.  TRIAL OF LOW-DOSE ASPIRIN PLUS DIPYRIDAMOLE VERSUS ANTICOAGULANTS FOR PREVENTION OF AORTOCORONARY VEIN GRAFT OCCLUSION , 1989, The Lancet.

[29]  M. Masotti,et al.  Prevention of aortocoronary vein-graft attrition with low-dose aspirin and triflusal, both associated with dipyridamole: a randomized, double-blind, placebo-controlled trial. , 1989, European heart journal.

[30]  Thomas E. Moritz,et al.  Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. , 1988, Circulation.

[31]  P. Rigo,et al.  Prevention of aorta-coronary bypass graft occlusion. Beneficial effect of ticlopidine on early and late patency rates of venous coronary bypass grafts: a double-blind study. , 1987, The Journal of thoracic and cardiovascular surgery.

[32]  J. Pirk,et al.  Improved patency of the aortocoronary bypass by antithrombotic drugs. , 1986, The Annals of thoracic surgery.

[33]  S. Rajah,et al.  Acetylsalicylic acid and dipyridamole improve the early patency of aorta-coronary bypass grafts. A double-blind, placebo-controlled, randomized trial. , 1985, The Journal of thoracic and cardiovascular surgery.

[34]  B. G. Brown,et al.  Improved graft patency in patients treated with platelet-inhibiting therapy after coronary bypass surgery. , 1985, Circulation.

[35]  J. Pepper,et al.  Randomised placebo controlled trial of aspirin and dipyridamole in the prevention of coronary vein graft occlusion. , 1985, British heart journal.

[36]  P. Weber,et al.  IMPROVED AORTOCORONARY BYPASS PATENCY BY LOW-DOSE ASPIRIN (100 mg DAILY) Effects on Platelet Aggregation and Thromboxane Formation , 1984, The Lancet.

[37]  P. Rigo,et al.  Effect of ticlopidine on saphenous vein bypass patency rates: a double-blind study. , 1984, The Annals of thoracic surgery.

[38]  V. Fuster,et al.  Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations. , 1984, The New England journal of medicine.

[39]  M. Frick,et al.  The Effect of Dipyridamole and Warfarin on the Patency Rate of Coronary Artery Bypass Grafts , 1983, The Thoracic and cardiovascular surgeon.

[40]  S. Khuri,et al.  The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency. , 1983, Circulation.

[41]  H. Baur,et al.  Effects of sulfinpyrazone on early graft closure after myocardial revascularization. , 1982, The American journal of cardiology.

[42]  S. Gates,et al.  The effect of antithrombotic therapy on patency rates of saphenous vein coronary artery bypass grafts. , 1982, The Journal of thoracic and cardiovascular surgery.

[43]  M. Schmuziger,et al.  Improved Graft Patency with Anticoagulant Therapy After Aortocoronary Bypass Surgery: A Prospective, Randomized Study , 1981, Circulation.

[44]  J. Mayer,et al.  Influence of aspirin and dipyridamole on patency of coronary artery bypass grafts. , 1981, The Annals of thoracic surgery.

[45]  S. Rahimtoola,et al.  Failure of antiplatelet and anticoagulant therapy to improve patency of grafts after coronary-artery bypass: a controlled, randomized study. , 1979, The New England journal of medicine.

[46]  R. Frye,et al.  Pathologic changes in aortocoronary saphenous vein grafts. , 1974, The American journal of cardiology.