Reduction of Preoperative Waiting Time before Urgent Surgery for Patients on P2Y12 Inhibitors Using Multiple Electrode Aggregometry: A Retrospective Study.

Michaël Hardy,Hugues Jacqmin,Anne-Sophie Dincq,Sarah Lessire,Thomas Lecompte,Camie Dupuis,François Mullier

doi:10.3390/jcm9020424

Michaël Hardy, Hugues Jacqmin + Show 5 more

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https://doi.org/10.3390/jcm9020424

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Abstract

P2Y12 inhibitor discontinuation is essential before most surgical interventions to limit bleeding complications. Based on pharmacodynamic data, fixed discontinuation durations have been recommended. However, as platelet function recovery is highly variable among patients, a more individualized approach based on platelet function testing (PFT) has been proposed. The aim of this retrospective single-centre study was to determine whether PFT using whole blood adenosine diphosphate–multiple electrode aggregometry (ADP–MEA) was associated with a safe reduction of preoperative waiting time. Preoperative ADP–MEA was performed for 29 patients on P2Y12 inhibitors. Among those, 17 patients underwent a coronary artery bypass graft. Twenty one were operated with an ADP–MEA ≥ 19 U (quantification of the area under the aggregation curve), and the waiting time was shorter by 1.6 days (median 1.8 days, IQR 0.5–2.9), by comparison with the current recommendations (five days for clopidogrel and ticagrelor, seven days for prasugrel). Platelet function recovery was indeed highly variable among individuals. With the 19 U threshold, high residual platelet inhibition was associated with perioperative platelet transfusion. These results suggest that preoperative PFT with ADP–MEA could help reduce waiting time before urgent surgery for patients on P2Y12 inhibitors.

Highlights

P2Y12 inhibitors are antiplatelet drugs recommended for secondary thrombosis prophylaxis after coronary, cerebral, or peripheral artery thrombosis [1]
We explored whether the adenosine diphosphate–multiple electrode aggregometry (ADP–multiple electrode aggregometry (MEA)) value was predictive of perioperative platelets or packed red blood cells (PRBC) transfusions, and whether the 19 U threshold was predictive of perioperative platelets or PRBC transfusions
Three patients received preoperative tirofiban infusion (GPIIb/IIIa inhibitor), which had been started after percutaneous coronary intervention (PCI) and discontinued 0, 4, and 6 h preoperatively (0, 3, and 6 h before MEA analysis, respectively); they had been operated with an adenosine diphosphate (ADP)–MEA equal to 1, 9, and 37 U, 0, 1, and 3 days after P2Y12 inhibitor discontinuation, respectively

Summary

Introduction

P2Y12 inhibitors are antiplatelet drugs recommended for secondary thrombosis prophylaxis after coronary, cerebral, or peripheral artery thrombosis [1]. Residual P2Y12 receptor inhibition has been associated with postoperative bleeding, blood transfusion, and re-exploration for bleeding after cardiac surgery [2]. Current guidelines recommend five days of discontinuation for clopidogrel and ticagrelor and seven days of discontinuation for prasugrel before elective surgery to avoid significant residual antiplatelet effect [3,4]. Clopidogrel and prasugrel are prodrugs that both irreversibly inhibit the P2Y12 subtype of adenosine diphosphate (ADP) receptor, the latter achieves a greater inhibition, requiring a longer discontinuation duration. Ticagrelor and one of its active metabolites act directly and reversibly, but inhibit strongly the P2Y12 ADP receptor, requiring a preoperative discontinuation of five days

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