Interpretation of 2024 EACTS guidelines on perioperative medication in adult cardiac surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHU Yunpeng ¹ , ZHANG Heng ^2,3 , HAN Mengyuan ¹ , HAN Jiawei ^2,3 ,  ZHENG Zhe ^2,3 ,  ZHAO Qiang ¹

1. Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P. R. China;
2. National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, 100037, P. R. China;
3. National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

ZHENG Zhe, Email: zhengzhe@fuwai.com; ZHAO Qiang, Email: zq11607@rjh.com.cn

Keywords：

Cardiac surgery; perioperative medication; secondary prevention; guidelines interpretation

DOI：

10.7507/1007-4848.202505072

Video：

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[Abstract] The European Association for Cardio-Thoracic Surgery (EACTS) has recently updated and published the “2024 EACTS guidelines on perioperative medication in adult cardiac surgery”. Based on the latest evidences, the guidelines have been updated in multiple aspects including underlying disease management, antithrombotic medication, arrhythmia treatment and other supportive care, etc. This paper aims to summarize and interpret the guidelines, in order to promote clinicians’ understanding and optimize perioperative medical treatment in adult cardiac surgery.

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2.	Sousa-Uva M, Head SJ, Milojevic M, et al. 2017 EACTS guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg, 2018, 53(1): 5-33.
3.	Sousa-Uva M, Head SJ, Thielmann M, et al. Methodology manual for European Association for Cardio-Thoracic Surgery (EACTS) clinical guidelines. Eur J Cardiothorac Surg, 2015, 48(6): 809-816.
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10.	Zheng Z, Jayaram R, Jiang L, et al. Perioperative rosuvastatin in cardiac surgery. N Engl J Med, 2016, 374(18): 1744-1753.
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25.	Jones HU, Muhlestein JB, Jones KW, et al. Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports. Circulation, 2002, 106(12 Suppl 1): Ⅰ19-Ⅰ22.
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34.	Brennan JM, Edwards FH, Zhao Y, et al. Early anticoagulation of bioprosthetic aortic valves in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. J Am Coll Cardiol, 2012, 60(11): 971-977.
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1. Jeppsson A, Rocca B, Hansson EC, et al. 2024 EACTS guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg, 2024, 67(1): ezae355.
2. Sousa-Uva M, Head SJ, Milojevic M, et al. 2017 EACTS guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg, 2018, 53(1): 5-33.
3. Sousa-Uva M, Head SJ, Thielmann M, et al. Methodology manual for European Association for Cardio-Thoracic Surgery (EACTS) clinical guidelines. Eur J Cardiothorac Surg, 2015, 48(6): 809-816.
4. Forrest JK, Deeb GM, Yakubov SJ, et al. 3-year outcomes after transcatheter or surgical aortic valve replacement in low-risk patients with aortic stenosis. J Am Coll Cardiol, 2023, 81(17): 1663-1674.
5. Fearon WF, Zimmermann FM, De Bruyne B, et al. Fractional flow reserve-guided PCI as compared with coronary bypass surgery. N Engl J Med, 2022, 386(2): 128-137.
6. LaPar DJ, Gillen JR, Crosby IK, et al. Predictors of operative mortality in cardiac surgical patients with prolonged intensive care unit duration. J Am Coll Surg, 2013, 216(6): 1116-1123.
7. Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA, 2014, 312(6): 616-622.
8. Kosmidou I, Chen S, Kappetein AP, et al. New-onset atrial fibrillation after PCI or CABG for left main disease: the EXCEL Trial. J Am Coll Cardiol, 2018, 71(7): 739-748.
9. White CM, Caron MF, Kalus JS, et al. Intravenous plus oral amiodarone, atrial septal pacing, or both strategies to prevent post-cardiothoracic surgery atrial fibrillation: the Atrial Fibrillation Suppression Trial Ⅱ (AFIST Ⅱ). Circulation, 2003, 108 Suppl 1: Ⅱ200.
10. Zheng Z, Jayaram R, Jiang L, et al. Perioperative rosuvastatin in cardiac surgery. N Engl J Med, 2016, 374(18): 1744-1753.
11. Billings FT, Hendricks PA, Schildcrout JS, et al. High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery: a randomized clinical trial. JAMA, 2016, 315(9): 877-888.
12. Liakopoulos OJ, Kuhn EW, Hellmich M, et al. Statin loading before coronary artery bypass grafting: a randomized trial. Eur Heart J, 2023, 44(25): 2322-2331.
13. Mangano DT,. Aspirin and mortality from coronary bypass surgery. N Engl J Med, 2002, 347(17): 1309-1317.
14. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol, 2011, 57(6): 672-684.
15. Smith PK, Goodnough LT, Levy JH, et al. Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis. J Am Coll Cardiol, 2012, 60(5): 388-396.
16. Hansson EC, Jidéus L, Åberg B, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study. Eur Heart J, 2016, 37(2): 189-197.
17. Gurbel PA, Bliden KP, Butler K, et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation, 2009, 120(25): 2577-2585.
18. Kwak YL, Kim JC, Choi YS, et al. Clopidogrel responsiveness regardless of the discontinuation date predicts increased blood loss and transfusion requirement after off-pump coronary artery bypass graft surgery. J Am Coll Cardiol, 2010, 56(24): 1994-2002.
19. Angiolillo DJ, Firstenberg MS, Price MJ, et al. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA, 2012, 307(3): 265-274.
20. Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation, 2004, 110(10): 1202-1208.
21. Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA, 2018, 319(16): 1677-1686.
22. Zhu Y, Zhang W, Dimagli A, et al. Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial. BMJ, 2024, 385: e075707.
23. Solo K, Lavi S, Kabali C, et al. Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis. BMJ, 2019, 367: l5476.
24. Sandner S, Redfors B, Angiolillo DJ, et al. Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery: a systematic review and meta-analysis. JAMA, 2022, 328(6): 554-562.
25. Jones HU, Muhlestein JB, Jones KW, et al. Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports. Circulation, 2002, 106(12 Suppl 1): Ⅰ19-Ⅰ22.
26. Kovacs MJ, Kearon C, Rodger M, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation, 2004, 110(12): 1658-1663.
27. Meurin P, Tabet JY, Weber H, et al. Low-molecular-weight heparin as a bridging anticoagulant early after mechanical heart valve replacement. Circulation, 2006, 113(4): 564-569.
28. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation, 1994, 89(2): 635-641.
29. Mok CK, Boey J, Wang R, et al. Warfarin versus dipyridamole-aspirin and pentoxifylline-aspirin for the prevention of prosthetic heart valve thromboembolism: a prospective randomized clinical trial. Circulation, 1985, 72(5): 1059-1063.
30. Puskas JD, Gerdisch M, Nichols D, et al. Anticoagulation and antiplatelet strategies after on-X mechanical aortic valve replacement. J Am Coll Cardiol, 2018, 71(24): 2717-2726.
31. Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med, 2013, 369(13): 1206-1214.
32. Laffort P, Roudaut R, Roques X, et al. Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study. J Am Coll Cardiol, 2000, 35(3): 739-746.
33. Heneghan C, Ward A, Perera R, et al. Self-monitoring of oral anticoagulation: systematic review and meta-analysis of individual patient data. Lancet, 2012, 379(9813): 322-334.
34. Brennan JM, Edwards FH, Zhao Y, et al. Early anticoagulation of bioprosthetic aortic valves in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. J Am Coll Cardiol, 2012, 60(11): 971-977.
35. Russo A, Grigioni F, Avierinos JF, et al. Thromboembolic complications after surgical correction of mitral regurgitation incidence, predictors, and clinical implications. J Am Coll Cardiol, 2008, 51(12): 1203-1211.
36. Guimarães HP, Lopes RD, de Barros E Silva PGM, et al. Rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve. N Engl J Med, 2020, 383(22): 2117-2126.
37. Brouwer J, Nijenhuis VJ, Delewi R, et al. Aspirin with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 383(15): 1447-1457.
38. Dangas GD, Tijssen JGP, Wöhrle J, et al. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. N Engl J Med, 2020, 382(2): 120-129.
39. Collet JP, Van Belle E, Thiele H, et al. Apixaban vs. standard of care after transcatheter aortic valve implantation: the ATLANTIS trial. Eur Heart J, 2022, 43(29): 2783-2797.
40. Nijenhuis VJ, Brouwer J, Delewi R, et al. Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 382(18): 1696-1707.
41. Van Mieghem NM, Unverdorben M, Hengstenberg C, et al. Edoxaban versus vitamin K antagonist for atrial fibrillation after TAVR. N Engl J Med, 2021, 385(23): 2150-2160.
42. Gaudino M, Di Franco A, Rong LQ, et al. Postoperative atrial fibrillation: from mechanisms to treatment. Eur Heart J, 2023, 44(12): 1020-1039.
43. Kirchhof P, Camm AJ, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med, 2020, 383(14): 1305-1316.
44. Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate control versus rhythm control for atrial fibrillation after cardiac surgery. N Engl J Med, 2016, 374(20): 1911-1921.
45. El-Chami MF, Kilgo P, Thourani V, et al. New-onset atrial fibrillation predicts long-term mortality after coronary artery bypass graft. J Am Coll Cardiol, 2010, 55(13): 1370-1376.
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Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesInterpretation of 2024 EACTS guidelines on perioperative medication in adult cardiac surgery

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