Impact of Preoperative Antiplatelet Therapy and Major Bleeding Complications after Emergency Coronary Artery Bypass Grafting in Patients with Acute Coronary Syndromes: A Current Report of the North-Rhine-Westphalia Surgical Myocardial Infarction Registry

Objectives: Preoperative management of patients who are emergently referred to coronary artery bypass grafting (CABG) being on antiplatelet therapy due to acute coronary syndromes (ACS) is contentious and involves the clinical dilemma of balancing the risk between CABG-related major bleeding and myocardial ischemia due to antiplatelet discontinuation before surgery. We aimed to evaluate the current state of the art and clinical outcomes and CABG-related major bleeding event rate of CABG surgery in ACS patients on a multicentric basis.

Methods: Multicentric data were obtained from “The North-Rhine-Westphalia Surgical Myocardial Infarction Registry” with > 120 patients characteristics and outcome variables. Patients undergoing CABG surgery with unstable angina (UAP) non-ST-elevation myocardial infarction (NSTEMI) or ST-elevation myocardial infarction (STEMI) were enrolled. CABG-related major bleeding was defined following the BARC type 4 criteria.

Results: Between January 2010 and December 2017, a total of 2,432 patients (age: 68 ± 11 years, male: 78%) were admitted to CABG surgery with UAP (25%), NSTEMI (50%), or STEMI (25%). Logistic Euroscore was 15.1 ± 15.1% in UAP, 20.3 ± 20.1% in NSTEMI, and 23.5 ± 20.0% in STEMI. A total of 36% of the patients had a history of prior PCI (24.5% UAP, 27.8% NSTEMI, and 38.8% STEMI). On the day of admission, 94, 95, and 95% UAP, NSTEMI, and STEMI patients were on aspirin; 36.2, 50.7, and 55.2% on P2Y12 inhibitors; 3.1, 6.6, and 14.8% on GIIb/IIIa inhibitors; and 36.2, 51.7, and 56% on dual-antiplatelet therapy, respectively. CABG-related bleeding complications (BARC type 4) occurred in 17.2% in UAP, 15.0% in NSTEMI, and 25.0% in STEMI patients. In-hospital mortality and MACCE rate occurred in 4.2, 7.6, 12.6% and 7.9, 16.7, 28.5% in UAP, NSTEMI, and STEMI, respectively. In patients with CABG-related bleeding, in-hospital mortality and MACCE rate significantly increased to 11.8, 18.7%, and 25.5% (p < 0.001) and 16.7, 35.7, and 54.9% (p < 0.001).

Conclusion: “The North-Rhine-Westphalia Surgical Myocardial Infarction Registry” showed that preoperative antiplatelet therapy in patients undergoing emergency CABG due to ACS is associated with CABG-related (BARC4) major bleeding complications, which in turn increases the risk of in-hospital mortality and MACCE more than twofold.