Anticoagulation and antiplatelet therapy post coronary artery bypass surgery

Understanding Drug Interactions in Antiplatelet Therapy for Atherosclerotic Vascular Disease: A Systematic Review

BACKGROUND

Antiplatelet drugs are a cornerstone in managing atherosclerotic vascular disease (ASVD). However, their interactions with other medications present significant challenges to treatment efficacy and safety. Patients with ASVD often require multiple treatment regimens due to complex comorbidities, which increases the risk of drug-drug interactions (DDIs). These interactions can lead to drug resistance, reduced therapeutic outcomes, or adverse effects. A thorough understanding of DDIs is crucial for optimizing patient care.

AIMS

This review aims to explore the clinical significance. mechanisms, and implications of DDIs in antiplatelet therapy Additionally, it seeks to identify future research directions to advance personalized treatment strategies and improve therapeutic outcomes.

MATERIALS AND METHODS

A systematic literature review was conducted using key databases, focusing on clinical studies, mechanistic research, and guidelines related to antiplatelet therapy and DDIs. Findings were analyzed to identify common interaction patterns, associated risks, and management strategies.

RESULTS

The review identifies common DDIs involving antiplatelet drugs, particularly with anticoagulants, nonsteroidal anti-inflammatory drugs, and proton pump inhibitors. These interactions primarily occur through pharmacokinetic mechanisms, such as alterations in drug metabolism via cytochrome P450 enzymes, and pharmacodynamic mechanisms, including synergistic or antagonistic effects on platelet inhibition. Clinically, DDIs can increase bleeding risk, reduce antiplatelet efficacy, and contribute to adverse cardiovascular outcomes. Strategies to mitigate these risks include individualized drug selection, dose adjustments, genetic testing, and therapeutic drug monitoring.

DISCUSSION

Effective management of DDIs in antiplatelet therapy is essential to improve clinical outcomes. A patient-specific approach, considering comorbidities, genetic predispositions, and concurrent medications, is crucial. The review categorizes DDIs based on clinical settings and underscores the need for further research on predictive biomarkers, pharmacogenomics, and advanced monitoring techniques.

CONCLUSION

DDIs significantly impact the effectiveness and safety of antiplatelet therapy, necessitating a comprehensive understanding of their mechanisms and clinical implications. Future research should focus on developing personalized treatment approaches, integrating genetic testing, and optimizing pharmacological monitoring to minimize risks and improve therapeutic outcomes. This review provides a foundation for advancing clinical practice and enhancing the management of patients with ASVD.

Enhancing mortality prediction after coronary artery bypass graft: a machine learning approach utilizing EuroScore

Aim: We developed a machine learning model using EuroScore assumptions and preoperative and intraoperative risk factors to predict mortality after coronary artery bypass graft (CABG). Materials & methods: We retrospectively examined data from 108 CABG patients at King Abdullah University Hospital, classifying them into risk groups via EuroScore and predicting mortality through random forest classification. Results: High-risk patients displayed longer surgical times and significant factors such as age and surgery choice. The median EuroScore was 0.95 (0.5-6.4). The model yielded high AUC scores (0.98, 0.95) indicating strong predictive accuracy. Conclusion: Our findings showed that the machine learning models combined with the EuroScore significantly improve post-CABG mortality prediction. For further validation, larger datasets are needed.

Progress Analysis of Personalized Antiplatelet Therapy in Patients with Coronary Heart Disease Undergoing Interventional Therapy

Coronary atherosclerosis (or coronary heart disease [CHD]) is a common cardiovascular disease that seriously damages human health. Percutaneous coronary stent implantation represents the primary treatment option for severe CHD in clinical practice; meanwhile, dual antiplatelet therapy (DAPT) is widely used to reduce the risk of postoperative thrombosis. Although the mechanisms of action of the two most commonly used antiplatelet drugs, aspirin and clopidogrel, remain unclear, clinical studies have shown that some patients are susceptible to stent thrombosis-antiplatelet resistance (high on-treatment platelet reactivity [HTPR])-despite using these drugs. Therefore, screening for HTPR and formulating personalized antiplatelet therapies is necessary. Ticagrelor, indobufen, and rivaroxaban are the most common and safe antiplatelet drugs used in clinical practice, with broad application prospects. This review summarizes the mechanisms of action of existing antiplatelet drugs, reasons for personalized treatment, screening of antiplatelet reactions, and development of novel antiplatelet drugs.

Mechanobiology of the endothelium in vascular health and disease: in vitro shear stress models

In recent years, there has been growing evidence that vascular pathologies arise in sites experiencing an altered haemodynamic environment. Fluid shear stress (FSS) is an important contributor to vascular homeostasis and regulates endothelial cell (EC) gene expression, morphology, and behaviour through specialised mechanosensitive signalling pathways. The presence of an altered FSS profile is a pathological characteristic of many vascular diseases, with the most established example being the preferential localisation of atherosclerotic plaque development. However, the precise haemodynamic contributions to other vascular pathologies including coronary artery vein graft failure remains poorly defined. To evaluate potential novel therapeutics for the treatment of vascular diseases via targeting EC behaviour, it is important to undertake in vitro experiments using appropriate culture conditions, particularly FSS. There are a wide range of in vitro models used to study the effect of FSS on the cultured endothelium, each with the ability to generate FSS flow profiles through which the investigator can control haemodynamic parameters including flow magnitude and directionality. An important consideration for selection of an appropriate model of FSS exposure is the FSS profile that the model can generate, in comparison to the physiological and pathophysiological haemodynamic environment of the vessel of interest. A resource bringing together the haemodynamic environment characteristic of atherosclerosis pathology and the flow profiles generated by in vitro methods of applying FSS would be beneficial to researchers when selecting the appropriate model for their research. Consequently, here we summarise the widely used methods of exposing cultured endothelium to FSS, the flow profile they generate and their advantages and limitations in investigating the pathological contribution of altered FSS to vascular disease and evaluating novel therapeutic targets for the treatment and prevention of vascular disease.

Activated Partial Thromboplastin Time and Mortality in Coronary Artery Bypass Grafting Patients

Background. To evaluate the prognostic value of preoperative activated partial thromboplastin time (APTT) in patients who underwent coronary artery bypass grafting (CABG). Methods. All data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The study population was divided to two groups according to the optimal cut-off value of APTT calculated by X-tile software, and Cox proportional hazard model was used to define independent effect of APTT on 4-year mortality. Survival curves were estimated by the Kaplan-Meier method, and the area under the receiver-operating characteristic curve (AUC) was calculated to compare APTT with other severity scores. Propensity score matching (PSM) analysis were applied to ensure the robustness of this study. Results. A total of 2,706 patients were included. The optimal cut-off value of APTT for 4-year mortality was 44 seconds. The Cox proportional hazard model showed that patients with $\text{APTT}\ge 44$ had a significantly higher risk of all-cause death than those with $\text{APTT}<44$ both before (HR (95% CI), 1.42 (1.16-1.74), $P<0.001$ ) and after PSM (HR (95% CI), 1.47 (1.14-1.89), $P=0.003$ ). The survival curves showed that patients with longer APTT had a significantly lower 1-year and 4-year cumulative survival probability. The ROC of APTT combined with other severity scores significantly increased predictive ability for 1-year and 4-year mortality. Conclusions. A longer APTT (≥44) was associated with a higher risk of mortality and can serve as a prognostic predictor in CABG patients.

Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta-analysis aimed to compare clinical outcomes following off-pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56-1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.

Secondary prevention after coronary artery bypass grafting: Anticoagulation and antiplatelet therapy is only one factor

Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel/ticagrelor/prasugrel does not lead to improved graft patency rates or clinical outcomes after coronary artery bypass grafting (CABG) over aspirin monotherapy, at least for on pump CABG. The protective effects of DAPT tended to be observed to be greater extent in patients undergoing off pump CABG. In general, the addition of the potent thienopyridines increased the risk of major bleeding, although the incidence of major bleeding is relatively low after either on pump or off pump surgical revascularization. There is a lack of evidence that anticoagulation post-CABG provides any protection against graft failure, but it may decrease the incidence of major adverse cardiovascular events. However, antiplatelet and anti thrombotic therapy after CABG is only one component of secondary prevention that needs to be taken into consideration when optimizing the long-term outcomes of patients after CABG.