J Korean Med Sci.  2011 Aug;26(8):1041-1046. 10.3346/jkms.2011.26.8.1041.

Preoperative Aspirin Resistance does not Increase Myocardial Injury during Off-pump Coronary Artery Bypass Surgery

• Kim HJ
• Lee JM
• Seo JH
• Kim JH
• Hong DM
• Bahk JH
• Kim KB
• Jeon Y

• KMID: 1777842
• DOI: http://doi.org/10.3346/jkms.2011.26.8.1041

Abstract

We performed a prospective cohort trial on 220 patients undergoing elective off-pump coronary artery bypass surgery and taking aspirin to evaluate the effect of aspirin resistance on myocardial injury. The patients were divided into aspirin responders and aspirin non-responders by the value of the aspirin reaction units obtained preoperatively using the VerifyNow(TM) Aspirin Assay. The serum levels of troponin I were measured before surgery and 1, 6, 24, 48 and 72 hr after surgery. In-hospital major adverse cardiac and cerebrovascular events, graft occlusion, the postoperative blood loss and reexploration for bleeding were recorded. Of the 220 patients, 181 aspirin responders (82.3%) and 39 aspirin non-responders (17.7%) were defined. There were no significant differences in troponin I levels (ng/mL) between aspirin responders and aspirin non-responders: preoperative (0.04 +/- 0.08 vs 0.03 +/- 0.06; P = 0.56), postoperative 1 hr (0.72 +/- 0.87 vs 0.86 +/- 1.10; P = 0.54), 6 hr (2.92 +/- 8.76 vs 1.50 +/- 2.40; P = 0.94), 24 hr (4.16 +/- 13.44 vs 1.25 +/- 1.95; P = 0.52), 48 hr (2.15 +/- 7.06 vs 0.65 +/- 0.95; P = 0.64) and 72 hr (1.20 +/- 4.63 vs 0.38 +/- 0.56; P = 0.47). Moreover, no significant differences were observed with regard to in-hospital outcomes. In conclusion, preoperative aspirin resistance does not increase myocardial injury in patients undergoing off-pump coronary artery bypass surgery. Postoperative dual antiplatelet therapy might have protected aspirin resistant patients.

Keyword

Aspirin; Coronary Artery Bypass, Off-Pump; Drug Resistance; Hemorrhage; Troponin I

MeSH Terms

Aged
Aspirin/*administration & dosage
Cohort Studies
Coronary Artery Bypass, Off-Pump/*adverse effects
Coronary Disease/*surgery
Drug Resistance
Female
Humans
Male
Middle Aged
Myocardial Infarction/etiology
Myocardial Reperfusion Injury/*prevention & control
Platelet Aggregation Inhibitors/*administration & dosage
Postoperative Hemorrhage/etiology
Preoperative Care/methods
Prospective Studies
Stroke/etiology
Troponin I/blood

Figure

• 

  Fig. 1 Flow diagram. ARU, aspirin reaction units.

Reference

1. Vane JR. Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. Nat New Biol. 1971. 231:232–235.

2. Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Doherty J, Read R, Chesler E, Sako Y. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. Circulation. 1988. 77:1324–1332.

3. Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T, Kern KB, Sethi G, Sharma GV, Khuri S. Long-term graft patency (3 years) after coronary artery surgery. Effects of aspirin: results of a VA Cooperative study. Circulation. 1994. 89:1138–1143.

4. Mangano DT. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002. 347:1309–1317.

5. Gum PA, Kottke-Marchant K, Welsh PA, White J, Topol EJ. A prospective, blinded determination of the natural history of aspirin resistance among stable patients with cardiovascular disease. J Am Coll Cardiol. 2003. 41:961–965.

6. Pamukcu B, Oflaz H, Onur I, Oncul A, Ozcan M, Umman B, Mercanoglu F, Meric M, Nisanci Y. Clinical relevance of aspirin resistance in patients with stable coronary artery disease: a prospective follow-up study (PROSPECTAR). Blood Coagul Fibrinolysis. 2007. 18:187–192.

7. Poston RS, Gu J, Brown JM, Gammie JS, White C, Nie L, Pierson RN 3rd, Griffith BP. Endothelial injury and acquired aspirin resistance as promoters of regional thrombin formation and early vein graft failure after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006. 131:122–130.

8. Yilmaz MB, Balbay Y, Caldir V, Ayaz S, Guray Y, Guray U, Korkmaz S. Late saphenous vein graft occlusion in patients with coronary bypass: possible role of aspirin resistance. Thromb Res. 2005. 115:25–29.

9. Peivandi AA, Dahm M, Hake U, Hafner G, Opfermann UT, Loos AH, Tzanova I, Oelert H. Patterns and diagnostic value of cardiac troponin I vs. troponin T and CKMB after OPCAB surgery. Thorac Cardiovasc Surg. 2001. 49:137–143.

10. Peivandi AA, Dahm M, Opfermann UT, Peetz D, Doerr F, Loos A, Oelert H. Comparison of cardiac troponin I versus T and creatine kinase MB after coronary artery bypass grafting in patients with and without perioperative myocardial infarction. Herz. 2004. 29:658–664.

11. van Werkum JW, Harmsze AM, Elsenberg EH, Bouman HJ, ten Berg JM, Hackeng CM. The use of the VerifyNow system to monitor antiplatelet therapy: a review of the current evidence. Platelets. 2008. 19:479–488.

12. Gavaghan TP, Gebski V, Baron DW. Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. A placebo-controlled, randomized study. Circulation. 1991. 83:1526–1533.

13. Dacey LJ, Munoz JJ, Johnson ER, Leavitt BJ, Maloney CT, Morton JR, Olmstead EM, Birkmeyer JD, O'Connor GT. Northern New England Cardiovascular Disease Study Group. Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients. Ann Thorac Surg. 2000. 70:1986–1990.

14. Møller CH, Steinbrüchel DA. Platelet function after coronary artery bypass grafting: is there a procoagulant activity after off-pump compared with on-pump surgery? Scand Cardiovasc J. 2003. 37:149–153.

15. Zimmermann N, Kurt M, Wenk A, Winter J, Gams E, Hohlfeld T. Is cardiopulmonary bypass a reason for aspirin resistance after coronary artery bypass grafting? Eur J Cardiothorac Surg. 2005. 27:606–610.

16. Suwalski G, Suwalski P, Filipiak KJ, Postuła M, Majstrak F, Opolski G. The effect of off-pump coronary artery bypass grafting on platelet activation in patients on aspirin therapy until surgery day. Eur J Cardiothorac Surg. 2008. 34:365–369.

17. Chen ZM, Jiang LX, Chen YP, Xie JX, Pan HC, Peto R, Collins R, Liu LS. COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005. 366:1607–1621.

18. Steinhubl SR, Berger PB, Mann JT 3rd, Fry ET, DeLago A, Wilmer C, Topol EJ. CREDO Investigators. Clopidogrel for the Reduction of Events During Observation. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002. 288:2411–2420.

19. Gasparyan AY, Watson T, Lip GY. The role of aspirin in cardiovascular prevention: implications of aspirin resistance. J Am Coll Cardiol. 2008. 51:1829–1843.

20. Srinivasan AK, Grayson AD, Pullan DM, Fabri BM, Dihmis WC. Effect of preoperative aspirin use in off-pump coronary artery bypass operations. Ann Thorac Surg. 2003. 76:41–45.

21. Gulbins H, Malkoc A, Ennker IC, Ennker J. Preoperative platelet inhibition with ASA does not influence postoperative blood loss following coronary artery bypass grafting. Thorac Cardiovasc Surg. 2009. 57:18–21.

22. Matsuura K, Imamaki M, Ishida A, Shimura H, Miyazaki M. The effect of preoperative aspirin administration on postoperative level of von Willebrand factor in off-pump coronary artery bypass surgery. Heart Vessels. 2009. 24:169–174.

23. Kallis P, Tooze JA, Talbot S, Cowans D, Bevan DH, Treasure T. Pre-operative aspirin decreases platelet aggregation and increases post-operative blood loss: a prospective, randomised, placebo controlled, double-blind clinical trial in 100 patients with chronic stable angina. Eur J Cardiothorac Surg. 1994. 8:404–409.

24. Morawski W, Sanak M, Cisowski M, Szczeklik M, Szczeklik W, Dropinski J, Waclawczyk T, Ulczok R, Bochenek A. Prediction of the excessive perioperative bleeding in patients undergoing coronary artery bypass grafting: role of aspirin and platelet glycoprotein IIIa polymorphism. J Thorac Cardiovasc Surg. 2005. 130:791–796.

25. Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol. 2008. 52:1693–1701.

26. Maltais S, Perrault LP, Do QB. Effect of clopidogrel on bleeding and transfusions after off-pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery. Eur J Cardiothorac Surg. 2008. 34:127–131.

27. Chan V, Kulik A, Bourke ME, Ressler L, Mesana TG, Ruel M. Clopidogrel is safe early after on- and off-pump coronary artery bypass surgery. J Card Surg. 2007. 22:493–497.

28. Hankey GJ, Eikelboom JW. Aspirin resistance. Lancet. 2006. 367:606–617.

29. Martin CP, Talbert RL. Aspirin resistance: an evaluation of current evidence and measurement methods. Pharmacotherapy. 2005. 25:942–953.