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Andrea Colli, Carlos A. Mestres, EACTS guideline on antiplatelet and anticoagulation management in cardiac surgery, European Journal of Cardio-Thoracic Surgery, Volume 35, Issue 1, January 2009, Page 197, https://doi.org/10.1016/j.ejcts.2008.10.001
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In the July issue of the EJCTS, Dunning and co-workers published the EACTS guidelines on antiplatelet and anticoagulation management in cardiac surgery [1]. We have read with great interest these guidelines and we would like to underline a few points that we understand need further clarification.
The ACC/AHA guidelines 2006 recommend the addition of aspirin 75–100 mg once daily to therapeutic warfarin for all patients with mechanical heart valves and those patients with biological valves who have risk factors (Level of Class I, Evidence: B) [2]. The ACCP 2008 guidelines recommend the addition of ASA only in patients with mechanical valves and additional factors for thromboembolism (AF, hypercoagulable state or low ejection fraction) (grade 1B).
The EACTS guidelines recommend that aspirin should be given postoperatively to all patients with CABG to improve graft patency with a dosage of 150–325 mg. The recommendation given is not acceptable because the currently available evidence is not in favor of this high dosage. Lower dosage such as 75–100 mg has shown to be effective; the advantage of using 325 mg is not statistically demonstrated, so from a legal point of view also, the EACTS should maintain the possibility to recommend a lower dosage too, as rightly stated by the ACCP 2008 guidelines and previously by the ACC/AHA guidelines [3].
It is so far not acceptable that the guidelines give an indication on the use of clopidogrel for the prevention of vein graft occlusion based on a study that has not been yet published, as well as indicating the use of clopidogrel and aspirin for 9–12 months for patients having cardiac surgery for acute coronary syndrome. The CAPRIE [4] and CURE [5] studies were not originally designed to investigate this topic; in addition, there was lack of information about cardiac surgery procedures.
Although guidelines are not law, they are gaining greater legal value; therefore, it would be necessary to keep the recommendations not so strict in the case of weak evidence as it is the case.
