Emma C Hansson1,2, Arnar Geirsson3,4, Vibeke Hjortdal5, Ari Mennander6, Christian Olsson7, Jarmo Gunn8, Igor Zindovic9,10, Anders Ahlsson11, Shahab Nozohoor9,10, Raphaelle A Chemtob12, Aldina Pivodic13, Tomas Gudbjartsson3, Anders Jeppsson1,2. 1. Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden. 2. Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. 3. Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland. 4. Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA. 5. Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark. 6. Department of Cardiothoracic Surgery, Heart Center Tampere University Hospital, Tampere, Finland. 7. Department of Thoracic and Cardiovascular Surgery, Karolinska University Hospital, Stockholm, Sweden. 8. Department of Surgery, Heart Center, Turku University Hospital, University of Turku, Turku, Finland. 9. Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden. 10. Department of Cardiothoracic Surgery, Lund University, Skane University Hospital, Lund, Sweden. 11. Department of Heart and Vascular Theme, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden. 12. Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. 13. Statistiska konsultgruppen, Gothenburg, Sweden.
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 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.
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-DAPTpatients with logistic regression models before and after propensity score matching. RESULTS: Before matching, 51.3% of DAPTpatients had major bleeding when compared to 37.7% of non-DAPTpatients (P = 0.0049). DAPTpatients 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 DAPTpatients, 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.