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Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair

Hansson, Emma C ; Geirsson, Arnar ; Hjortdal, Vibeke ; Mennander, Ari ; Olsson, Christian ; Gunn, Jarmo ; Zindovic, Igor LU ; Ahlsson, Anders ; Nozohoor, Shahab LU and Chemtob, Raphaelle A , et al. (2019) In European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 56(1). p.182-188
Abstract

OBJECTIVES: Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database.

METHODS: The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA + clopidogrel (n = 108) or ASA + ticagrelor (n = 11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic... (More)

OBJECTIVES: Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database.

METHODS: The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA + clopidogrel (n = 108) or ASA + ticagrelor (n = 11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic regression models before and after propensity score matching.

RESULTS: Before matching, 51.3% of DAPT patients had major bleeding when compared to 37.7% of non-DAPT patients (P = 0.0049). DAPT patients received more transfusions of red blood cells [median 8 U (Q1-Q3 4-15) vs 5.5 U (2-11), P < 0.0001] and platelets [4 U (2-8) vs 2 U (1-4), P = 0.0001]. Crude 30-day mortality was 19.3% vs 17.0% (P = 0.60). After matching, major bleeding remained significantly more common in DAPT patients, 51.3% vs 39.3% [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.51; P = 0.028], but mortality did not significantly differ (OR 0.88, 95% CI 0.51-1.50; P = 0.63). Major bleeding was associated with increased 30-day mortality (adjusted OR 2.44, 95% CI 1.72-3.46; P < 0.0001).

CONCLUSIONS: DAPT prior to acute aortic dissection repair was associated with increased bleeding and transfusions but not with mortality. Major bleeding per se was associated with a significantly increased mortality. Correct diagnosis is important to avoid DAPT and thereby reduce bleeding risk, but ongoing DAPT should not delay surgery.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
in
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
volume
56
issue
1
pages
182 - 188
publisher
Oxford University Press
external identifiers
  • pmid:30657880
  • scopus:85062601142
ISSN
1010-7940
DOI
10.1093/ejcts/ezy469
language
English
LU publication?
yes
id
1f59b223-c279-45ca-a202-b1d3e3948f23
date added to LUP
2019-05-22 09:11:44
date last changed
2024-05-28 11:34:53
@article{1f59b223-c279-45ca-a202-b1d3e3948f23,
  abstract     = {{<p>OBJECTIVES: Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database.</p><p>METHODS: The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA + clopidogrel (n = 108) or ASA + ticagrelor (n = 11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic regression models before and after propensity score matching.</p><p>RESULTS: Before matching, 51.3% of DAPT patients had major bleeding when compared to 37.7% of non-DAPT patients (P = 0.0049). DAPT patients received more transfusions of red blood cells [median 8 U (Q1-Q3 4-15) vs 5.5 U (2-11), P &lt; 0.0001] and platelets [4 U (2-8) vs 2 U (1-4), P = 0.0001]. Crude 30-day mortality was 19.3% vs 17.0% (P = 0.60). After matching, major bleeding remained significantly more common in DAPT patients, 51.3% vs 39.3% [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.51; P = 0.028], but mortality did not significantly differ (OR 0.88, 95% CI 0.51-1.50; P = 0.63). Major bleeding was associated with increased 30-day mortality (adjusted OR 2.44, 95% CI 1.72-3.46; P &lt; 0.0001).</p><p>CONCLUSIONS: DAPT prior to acute aortic dissection repair was associated with increased bleeding and transfusions but not with mortality. Major bleeding per se was associated with a significantly increased mortality. Correct diagnosis is important to avoid DAPT and thereby reduce bleeding risk, but ongoing DAPT should not delay surgery.</p>}},
  author       = {{Hansson, Emma C and Geirsson, Arnar and Hjortdal, Vibeke and Mennander, Ari and Olsson, Christian and Gunn, Jarmo and Zindovic, Igor and Ahlsson, Anders and Nozohoor, Shahab and Chemtob, Raphaelle A and Pivodic, Aldina and Gudbjartsson, Tomas and Jeppsson, Anders}},
  issn         = {{1010-7940}},
  language     = {{eng}},
  month        = {{01}},
  number       = {{1}},
  pages        = {{182--188}},
  publisher    = {{Oxford University Press}},
  series       = {{European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery}},
  title        = {{Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair}},
  url          = {{http://dx.doi.org/10.1093/ejcts/ezy469}},
  doi          = {{10.1093/ejcts/ezy469}},
  volume       = {{56}},
  year         = {{2019}},
}