Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry

Fausto Biancari, Giovanni Mariscalco, Riccardo Gherli, Daniel Reichart, Francesco Onorati, Giuseppe Faggian, Ilaria Franzese, Giuseppe Santarpino, Theodor Fischlein, Antonino S Rubino, Daniele Maselli, Saverio Nardella, Antonio Salsano, Francesco Nicolini, Marco Zanobini, Matteo Saccocci, Vito G Ruggieri, Karl Bounader, Andrea Perrotti, Stefano RosatoPaola D'Errigo, Vito D'Andrea, Marisa De Feo, Tuomas Tauriainen, Giuseppe Gatti, Magnus Dalén

Research output: Contribution to journalArticle

Abstract

Aims: No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG).

Methods and results: This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6%) ranged from 0.7% to 24.8% between centres (adjusted P < 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2-3, OR 1.66, 95% confidence interval (CI) 1.27-2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3-4, OR 1.50, 95% CI 1.16-1.93]. The incidence of resternotomy for bleeding (overall 2.6%) ranged from 0% to 6.9% (adjusted P < 0.0001), and surgical site bleeding (overall 59.6%) ranged from 0% to 84.6% (adjusted P = 0.003). The rate of the UDPB bleeding grades 3-4 (overall 8.4%) ranged from 3.7% to 22.3% (P < 0.0001), and of the E-CABG bleeding grades 2-3 (overall 6.5%) ranged from 0.4% to 16.4% between centres (P < 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95% CI 2.85-8.92), UDPB bleeding grades 3-4 (adjusted OR 6.61, 95% CI 4.42-9.88), and E-CABG bleeding grades 2-3 (adjusted OR 8.71, 95% CI 5.76-13.15) were associated with an increased risk of hospital/30-day mortality.

Conclusions: Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.

Original languageEnglish
Pages (from-to)246-257
Number of pages12
JournalEuropean heart journal. Quality of care & clinical outcomes
Volume4
Issue number4
DOIs
Publication statusPublished - Oct 1 2018

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Coronary Artery Bypass
Registries
Hemorrhage
Confidence Intervals
Purinergic P2Y Receptor Antagonists
Guidelines
Mortality
Multicenter Studies

Keywords

  • Aged
  • Blood Loss, Surgical/prevention & control
  • Blood Transfusion/standards
  • Coronary Artery Bypass
  • Coronary Artery Disease/surgery
  • Europe/epidemiology
  • Female
  • Fibrinolytic Agents/adverse effects
  • Humans
  • Incidence
  • Male
  • Practice Guidelines as Topic
  • Preoperative Care/standards
  • Prospective Studies
  • Thrombolytic Therapy/adverse effects

Cite this

Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting : results from the multicentre E-CABG registry. / Biancari, Fausto; Mariscalco, Giovanni; Gherli, Riccardo; Reichart, Daniel; Onorati, Francesco; Faggian, Giuseppe; Franzese, Ilaria; Santarpino, Giuseppe; Fischlein, Theodor; Rubino, Antonino S; Maselli, Daniele; Nardella, Saverio; Salsano, Antonio; Nicolini, Francesco; Zanobini, Marco; Saccocci, Matteo; Ruggieri, Vito G; Bounader, Karl; Perrotti, Andrea; Rosato, Stefano; D'Errigo, Paola; D'Andrea, Vito; De Feo, Marisa; Tauriainen, Tuomas; Gatti, Giuseppe; Dalén, Magnus.

In: European heart journal. Quality of care & clinical outcomes, Vol. 4, No. 4, 01.10.2018, p. 246-257.

Research output: Contribution to journalArticle

Biancari, F, Mariscalco, G, Gherli, R, Reichart, D, Onorati, F, Faggian, G, Franzese, I, Santarpino, G, Fischlein, T, Rubino, AS, Maselli, D, Nardella, S, Salsano, A, Nicolini, F, Zanobini, M, Saccocci, M, Ruggieri, VG, Bounader, K, Perrotti, A, Rosato, S, D'Errigo, P, D'Andrea, V, De Feo, M, Tauriainen, T, Gatti, G & Dalén, M 2018, 'Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry', European heart journal. Quality of care & clinical outcomes, vol. 4, no. 4, pp. 246-257. https://doi.org/10.1093/ehjqcco/qcy027
Biancari, Fausto ; Mariscalco, Giovanni ; Gherli, Riccardo ; Reichart, Daniel ; Onorati, Francesco ; Faggian, Giuseppe ; Franzese, Ilaria ; Santarpino, Giuseppe ; Fischlein, Theodor ; Rubino, Antonino S ; Maselli, Daniele ; Nardella, Saverio ; Salsano, Antonio ; Nicolini, Francesco ; Zanobini, Marco ; Saccocci, Matteo ; Ruggieri, Vito G ; Bounader, Karl ; Perrotti, Andrea ; Rosato, Stefano ; D'Errigo, Paola ; D'Andrea, Vito ; De Feo, Marisa ; Tauriainen, Tuomas ; Gatti, Giuseppe ; Dalén, Magnus. / Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting : results from the multicentre E-CABG registry. In: European heart journal. Quality of care & clinical outcomes. 2018 ; Vol. 4, No. 4. pp. 246-257.
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abstract = "Aims: No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG).Methods and results: This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6{\%}) ranged from 0.7{\%} to 24.8{\%} between centres (adjusted P < 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2-3, OR 1.66, 95{\%} confidence interval (CI) 1.27-2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3-4, OR 1.50, 95{\%} CI 1.16-1.93]. The incidence of resternotomy for bleeding (overall 2.6{\%}) ranged from 0{\%} to 6.9{\%} (adjusted P < 0.0001), and surgical site bleeding (overall 59.6{\%}) ranged from 0{\%} to 84.6{\%} (adjusted P = 0.003). The rate of the UDPB bleeding grades 3-4 (overall 8.4{\%}) ranged from 3.7{\%} to 22.3{\%} (P < 0.0001), and of the E-CABG bleeding grades 2-3 (overall 6.5{\%}) ranged from 0.4{\%} to 16.4{\%} between centres (P < 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95{\%} CI 2.85-8.92), UDPB bleeding grades 3-4 (adjusted OR 6.61, 95{\%} CI 4.42-9.88), and E-CABG bleeding grades 2-3 (adjusted OR 8.71, 95{\%} CI 5.76-13.15) were associated with an increased risk of hospital/30-day mortality.Conclusions: Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.",
keywords = "Aged, Blood Loss, Surgical/prevention & control, Blood Transfusion/standards, Coronary Artery Bypass, Coronary Artery Disease/surgery, Europe/epidemiology, Female, Fibrinolytic Agents/adverse effects, Humans, Incidence, Male, Practice Guidelines as Topic, Preoperative Care/standards, Prospective Studies, Thrombolytic Therapy/adverse effects",
author = "Fausto Biancari and Giovanni Mariscalco and Riccardo Gherli and Daniel Reichart and Francesco Onorati and Giuseppe Faggian and Ilaria Franzese and Giuseppe Santarpino and Theodor Fischlein and Rubino, {Antonino S} and Daniele Maselli and Saverio Nardella and Antonio Salsano and Francesco Nicolini and Marco Zanobini and Matteo Saccocci and Ruggieri, {Vito G} and Karl Bounader and Andrea Perrotti and Stefano Rosato and Paola D'Errigo and Vito D'Andrea and {De Feo}, Marisa and Tuomas Tauriainen and Giuseppe Gatti and Magnus Dal{\'e}n",
year = "2018",
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doi = "10.1093/ehjqcco/qcy027",
language = "English",
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pages = "246--257",
journal = "European heart journal. Quality of care & clinical outcomes",
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TY - JOUR

T1 - Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting

T2 - results from the multicentre E-CABG registry

AU - Biancari, Fausto

AU - Mariscalco, Giovanni

AU - Gherli, Riccardo

AU - Reichart, Daniel

AU - Onorati, Francesco

AU - Faggian, Giuseppe

AU - Franzese, Ilaria

AU - Santarpino, Giuseppe

AU - Fischlein, Theodor

AU - Rubino, Antonino S

AU - Maselli, Daniele

AU - Nardella, Saverio

AU - Salsano, Antonio

AU - Nicolini, Francesco

AU - Zanobini, Marco

AU - Saccocci, Matteo

AU - Ruggieri, Vito G

AU - Bounader, Karl

AU - Perrotti, Andrea

AU - Rosato, Stefano

AU - D'Errigo, Paola

AU - D'Andrea, Vito

AU - De Feo, Marisa

AU - Tauriainen, Tuomas

AU - Gatti, Giuseppe

AU - Dalén, Magnus

PY - 2018/10/1

Y1 - 2018/10/1

N2 - Aims: No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG).Methods and results: This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6%) ranged from 0.7% to 24.8% between centres (adjusted P < 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2-3, OR 1.66, 95% confidence interval (CI) 1.27-2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3-4, OR 1.50, 95% CI 1.16-1.93]. The incidence of resternotomy for bleeding (overall 2.6%) ranged from 0% to 6.9% (adjusted P < 0.0001), and surgical site bleeding (overall 59.6%) ranged from 0% to 84.6% (adjusted P = 0.003). The rate of the UDPB bleeding grades 3-4 (overall 8.4%) ranged from 3.7% to 22.3% (P < 0.0001), and of the E-CABG bleeding grades 2-3 (overall 6.5%) ranged from 0.4% to 16.4% between centres (P < 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95% CI 2.85-8.92), UDPB bleeding grades 3-4 (adjusted OR 6.61, 95% CI 4.42-9.88), and E-CABG bleeding grades 2-3 (adjusted OR 8.71, 95% CI 5.76-13.15) were associated with an increased risk of hospital/30-day mortality.Conclusions: Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.

AB - Aims: No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG).Methods and results: This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6%) ranged from 0.7% to 24.8% between centres (adjusted P < 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2-3, OR 1.66, 95% confidence interval (CI) 1.27-2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3-4, OR 1.50, 95% CI 1.16-1.93]. The incidence of resternotomy for bleeding (overall 2.6%) ranged from 0% to 6.9% (adjusted P < 0.0001), and surgical site bleeding (overall 59.6%) ranged from 0% to 84.6% (adjusted P = 0.003). The rate of the UDPB bleeding grades 3-4 (overall 8.4%) ranged from 3.7% to 22.3% (P < 0.0001), and of the E-CABG bleeding grades 2-3 (overall 6.5%) ranged from 0.4% to 16.4% between centres (P < 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95% CI 2.85-8.92), UDPB bleeding grades 3-4 (adjusted OR 6.61, 95% CI 4.42-9.88), and E-CABG bleeding grades 2-3 (adjusted OR 8.71, 95% CI 5.76-13.15) were associated with an increased risk of hospital/30-day mortality.Conclusions: Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.

KW - Aged

KW - Blood Loss, Surgical/prevention & control

KW - Blood Transfusion/standards

KW - Coronary Artery Bypass

KW - Coronary Artery Disease/surgery

KW - Europe/epidemiology

KW - Female

KW - Fibrinolytic Agents/adverse effects

KW - Humans

KW - Incidence

KW - Male

KW - Practice Guidelines as Topic

KW - Preoperative Care/standards

KW - Prospective Studies

KW - Thrombolytic Therapy/adverse effects

U2 - 10.1093/ehjqcco/qcy027

DO - 10.1093/ehjqcco/qcy027

M3 - Article

C2 - 29939246

VL - 4

SP - 246

EP - 257

JO - European heart journal. Quality of care & clinical outcomes

JF - European heart journal. Quality of care & clinical outcomes

SN - 2058-5225

IS - 4

ER -