RORY KELLEHER JOSEPHINE MAK DAVID J MCCORMACK ADAM

RORY KELLEHER, JOSEPHINE MAK, DAVID J MCCORMACK, ADAM EL GAMEL WAIKATO CARDIOTHORACIC UNIT

BACKGROUND • SAPHENOUS VEIN MOST COMMON IN CABG • EARLY GRAFT FAILURE - THROMBOSIS • DAPT IMPROVES PROGNOSIS • BENEFITS: PREVENTS GRAFT CLOSURE • RISKS: BLEEDING

AIM… TO PREVENT…! Acute thrombosis of SVG

CURRENT RECOMMENDATIONS 2016 ACC/AHA GUIDLINE aspirin and clopidogrel should be continued in ACS & SIHD patients for one year postoperatively

AIM • TO EVALUATE THE RECEIVED POSTOPERATIVEANTIPLATELET THERAPY OF CABG PATIENTS AT DISCHARGE

METHODS • 3 MONTHS OFPOST-CABG PATIENTS (JAN-MARCH 2016) • 69 PATIENTS • PATIENTS ON ANTICOAGULANT THERAPY EXCLUDED • DISCHARGE SUMMARIES ANALYSED • ANTIPLATELET MEDICATIONS PRESCRIBED • DURATION OF PROPOSED ANTIPLATELET THERAPY

RESULTS • DAPT ON DISCHARGE SUMMARIES WASMARKEDLY VARIED • 17 DIFFERENT REGIMENS WERE FOUND • VARYING LENGTH OF THERAPY AND AGENTS • MOST COMMON REGIMEN: 3 MONTHSASPIRIN & 3 MONTHSCLOPIDOGREL (27 PATIENTS) • NO PATTERN IN PRESCRIBING WHEN PATIENTS SEPARATED ACCORDING TO PREOPERATIVE STATUS (ACS, SIDH ORPCI)

DISCUSSION • CARDIOLOGY 6 WEEKS POST-OP, MEDS CHANGED? • MAX LENGTH PRESCRIPTION 3 MONTHS • DURATION SHOULD BE IN DISCHARGE PLAN • SHOULD BE CLEARLY DOCUMENTED BY THE CARDIOTHORACIC TEAM • GPS AND CARDIOLOGISTS • RELY TOO HEAVILY ON CARDIOLOGISTS? • NEED FOR A PROTOCOL?

CONCLUSION • DAPT NOT BEING DOCUMENTED APPROPRIATELY AT DISCHARGE • REQUIREMENT FOR AN INTERVENTION • APPLYING BEST PRACTICE MAY HELP FUTURE RESEARCH TO COMPARE THE EFFICACY OF PERCUTANEOUS STENTS WITH CABG.

HOW CAN WE IMPROVE?

SOLUTION? • POSTOPERATIVE ANTIPLATELET CARD • ISSUED TO PATIENTS LISTING THE CURRENTGUIDELINES, ANTIPLATELET PRESCRIBED AND THE RATIONALE FOR CHOOSING THIS REGIMEN. • PROMOTES PATIENT EMPOWERMENT

FUTURE RESEARCH • CLOSED LOOP AUDIT – REPEAT 3 MONTHS FOLLOWING INTERVENTION • ARE CARDIOLOGISTS CHANGING ANTIPLATELETS AT 6 WEEKS? • CONTACT GP’S – ARE PATIENTS STILL ON ANTIPLATELETS AT 12 MONTHS?

• CARDIOLOGISTS AND CT SURGEONS – TEAM. NOT ONE OR THE OTHER. • UPDATE GUIDELINES • IMPLEMENT CHANGE • EDUCATE STAFF • IMPROVE CARE

REFERENCES • HARSKAMP RE, LOPES RD, BAISDEN CE, DE WINTER RJ, ALEXANDER JH. SAPHENOUS VEIN GRAFT FAILURE AFTER CORONARY ARTERY BYPASS SURGERY: PATHOPHYSIOLOGY, MANAGEMENT, AND FUTURE DIRECTIONS. ANN SURG. 2013; 257(5): 824 -33. • BONG G GUN S SONG, H , HYUN S SUK Y YANG, J , JOON H HYUNG D DOH, H , HONG J JANG, G , GU H HYUN K KANG, Y , YONG H HWAN P PARK, W , WOO J JUNG C CHUN, J , JU H HYEON O OH, S , SUNG M MIN K KO AND H HWEUNG K KON H HWANG (2011). A A SSESSMENT OF C C ORONARY A A RTERY B B YPASS G G RAFT (CABG) ) P P ATENCY AND G G RAFT D D ISEASE U U SING M M ULTIDETECTOR C C OMPUTED T T OMOGRAPHY (MDCT), ), C C ORONARY A A NGIOGRAPHY - (2011). ( ADVANCES IN N N ONINVASIVE I I MAGING A A PPROACH FOR E E VALUATION OF C C ORONARY A A RTERY D D ISEASE , P P ROF. B B ASKOT B B RANISLAV (E E D. ), I N T ECH , DOI: 10. 5772/18913. A VAILABLE FROM : , . ( , HTTPS: //WWW. INTECHOPEN. COM/BOOKS/CORONARY-ANGIOGRAPHY-ADVANCES-IN-NONINVASIVE-IMAGING-APPROACH-FOR-EVALUATION-OF-CORONARY-ARTERY-DISEASE/ASSESSMENT-OFCORONARY-ARTERY-BYPASS-GRAFT-CABG-PATENCY-AND-GRAFT-DISEASE-USING-MULTIDETECTOR-COMPUT • FOX KA, MEHTA SR, PETERS R, ET AL. BENEFITS AND RISKS OF THE COMBINATION OF CLOPIDOGREL AND ASPIRIN IN PATIENTS UNDERGOING SURGICAL REVASCULARIZATION FOR NONSTELEVATION ACUTE CORONARY SYNDROME: THEC LOPIDOGREL IN UNSTABLE ANGINA TO PREVENT RECURRENT ISCHEMIC EVENTS (CURE) TRIAL. CIRCULATION 2004; 110: 1202. • GLENN N. LEVINE, ERIC R. BATES, JOHN A. BITTL, RALPH G. BRINDIS, STEPHAN D. FIHN, LEE A. FLEISHER, CHRISTOPHER B. GRANGER, RICHARD A. LANGE, MICHAEL J. MACK, LAURA MAURI, ROXANA MEHRAN, DEBABRATA MUKHERJEE, L. KRISTIN NEWBY, PATRICK T. O’GARA, MARC S. SABATINE, PETER K. SMITH AND SIDNEY C. SMITH. 2016 ACC/AHA GUIDELINE FOCUSED UPDATE ON DURATION OF DUAL ANTIPLATELET THERAPY IN PATIENTS WITH CORONARY ARTERY DISEASE: A REPORT OF THE AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION TASK FORCE ON CLINICAL PRACTICE GUIDELINES. CIRCULATION. 2016; 136: 2. • DEO, S. V. , DUNLAY, S. M. , SHAH, I. K. , ALTARABSHEH, S. E. , ERWIN, P. J. , BOILSON, B. A. , PARK, S. J. AND JOYCE, L. D. DUAL ANTI-PLATELET THERAPY AFTER CORONARY ARTERY BYPASS GRAFTING: IS THERE ANY BENEFIT? A SYSTEMATIC REVIEW AND META-ANALYSIS. J CARD SURG. 2013; 28 : 109 • KULIK A , H HIRATZKA LF , IIKONOMIDIS JS , LLOPEZ-J , P PATEL M , S SELLKE FW , S SICA DA , Z ZIMMERMAN L A, R , RUEL M M, J , JNEID H H, F , FERGUSON TB TB, LF, JS, -JIMENEZ F F, M , MCNALLAN SM SM, M, R , ROGER VL VL, FW, DA, L. S. SECONDARY PREVENTION AFTER CORONARY ARTERY BYPASS GRAFT SURGERY: A SCIENTIFIC STATEMENT FROM THEA MERICAN H HEART A ASSOCIATION. C. CIRCULATION. 2015; 131: 927 -64. • FAROOQ V , B BOURANTAS C HOLMES DR , K KAPPETEIN AP , M MACK M , C COLOMBO A , DE VRIES V, S , SERRUYS PW PW, C, V , VRANCKX P P, D , DILETTI R R, G , GARCIA G GARCIA HM, H DR, AP, M, F , FELDMAN T T, M , MORICE MC MC, A, M , MOREL MA MA, T, VAN E , S STEYERBERG EW , D DAWKINS KD , M MOHR FW , JJAMES S ES GA GA, EW, KD, FW, S, S , STÅHLE E E. I. INCIDENCE AND MULTIVARIABLE CORRELATES OF LONG-TERM MORTALITY IN PATIENTS TREATED WITH SURGICAL OR PERCUTANEOUS REVASCULARIZATION IN THE S ) TRIAL. EUR HEART J. SYNERGY B BETWEEN P PERCUTANEOUS C CORONARY I INTERVENTION W WITH T TAXUS AND C CARDIAC S SURGERY (SYNTAX) 2012; 33: 3105– 3113.