**1. Introduction**

Despite routine use of ASA before CABG, and lifelong following the revascularization, patients who undergo CABG remain at high risk of long-term events in any vascular bed (cerebrovas‐ cular, cardiovascular, peripheral). The handicap of management of antiplatelet agents in the perioperative period of cardiac surgery requires close collaboration between cardiologists, surgeons and anaesthesiologists. It is necessary to avoid thrombotic complications maintaining the antiagregation, but balancing bleeding complications. [1]

Combined antiplatelet therapy employing agents from different pharmacological classes is characterised by good safety and efficacy profiles.

Antiplatelet therapy and antithrombin therapy have been demonstrated to reduce the risk of cardiac events in patients presenting with acute coronary syndrome, yet all effective therapies also increase the risk of bleeding. Antiplatelet therapy and antithrombotic therapy have been demonstrated to favorably modify clinical outcome, and recent trials of revascularization in ACSs have demonstrated a reduction in the frequency of major cardiac events.[2-14]

Multiple clinical trials showed the favorable benefit/risk ratio of clopidogrel over aspirin justifying the indication for using clopidogrel in a wide range of at risk patients and in longterm prevention in various manifestations of atherosclerosis.[2-9]

Antiplatelet and antithrombin therapy can have synergistic actions that reduce the risk of spontaneous or revascularization, especially percutaneous coronary intervention (PCI)– related events. On the other hand, all effective antithrombotic agents also increase the risk of bleeding, especially bleeding that results from vascular access or associated with surgery, including coronary artery bypass grafting (CABG).

The Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) trial demonstrated that the combination of clopidogrel and aspirin was superior to aspirin alone for patients hospitalized with non–ST-elevation ACSs.[5] The therapy was in addition to the current standard of care, including heparin or low-molecular-weight heparin, antianginal therapy, and revascularization.[5, 6, 15].

**2.** To evaluate the importance and utility of antiplatelet therapy with Clopidogrel early postoperatively in the intensive care unit (ICU) for the prevention of postoperative

The Antiagregant Treatment After Coronary Artery Surgery Depending on Cost – Benefit Report

http://dx.doi.org/10.5772/54467

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**3.** To establish the prognostic implications of the type of the perioperative antiagregant regimen in patients with CABG and to determine which therapy can reduce hospital stay

**4.** To determine the indications for using Clopidogrel or Aspirin or Aspirin plus Clopidogrel in coronary artery surgery depending on the cost-benefit ratio and its economic implica‐

Randomized,, open label three years clinical trial with open study period, carried out on 1200 pts undergoing coronary artery bypass grafing divided in three parallel groups: Group A: Clopidogrel po 75 mg/day, Group B: Aspirin po 75 mg/day and Group C: Aspirin 75mg plus

**•** Enrollment phase – there were enrolled one thousand and two hundred patients undergoing

**•** Active treatment phase – after randomisation all patients received antiagregant therapy:

The treatment began the second day postoperatively and lasted no less than 1 year postoper‐

**•** follow –up phase – all patients were evaluated clinically and paraclinically daily for the first ten days and at one, three, six months and one year postoperatively. Patients were followed for a minimum of 1 to a maximum of 3 years, regardless of discontinuation of the study drug. Follow-up assessments took place at 1, 3, 6, and 12 months for all patients and at 1, 2

The study included all patients undergoing coronary artery bypass grafting, who underwent surgery in an Emergency Institute for Cardiovascular Diseases between January 1st 2008 and

**◦** Group C with combination of Aspirin 75 mg with Clopidogrel 75 mg.

after cardiac surgery and improve the quality of life of these patients.

complications

tions.

atively.

**4. Eligibility criteria**

**3. Methods and material**

Clopidogrel 75mg once daily.

The main phases of the study protocol were: (Figure 1)

and 3 years for patients randomized early in the study.

May 1st 2011 who did not have the non – eligibility criterias.

CABG, in the immediate postoperative period

**◦** Group A with Aspirin 75 mg daily

**◦** Goup B with Clopidogrel 75 mg daily

Actually the field of the indications of use of the Clopidogrel is being continuously updated. There are different type of patients who benefit from antiplatelet therapy [16, 17] Moreover the combination of two antiagregant drugs (mainly ASA and clopidogrel) in high risk patients is a practice more and more extended [18] and dual antiplatelet therapy is recommended and has to be maintained at least 12 months after drug eluting stent placement [19].

On the other hand, in patients undergoing coronary artery bypass grafting, immediate postoperative antiagregant regimens are only regulated for routinely use Aspirin.

Antiplatelet therapy is critical in the management of coronary artery disease. For patients undergoing coronary artery bypass graft surgery (CABG), controversy remains regarding the safety of preoperative antiplatelet therapy and the optimal postoperative antiplatelet regimen to maintain graft patency and reduce ischemic complications.

Despite > 30 years of experience with antiplatelet agents during CABG, questions remain regarding their perioperative safety and efficacy. The results of continuing randomized controlled trials should further clarify the role of perioperative aspirin and clopidogrel therapy and help redefine the modern antiplatelet management of coronary artery bypass patients.

Following surgery, extensive evidence supports the use of aspirin, in doses of 100 - 325 mg daily, to be administered in 48 h postoperatively and continued indefinitely. Less is known regarding the use of clopidogrel following CABG, although it is now recommended as postoperative antiplatelet therapy in patients with recent acute coronary syndromes.[20]

It is very important to identify the optimal timing and dose ofAaspirin following CABG, and to assess the role of postoperative Clopidogrel therapy.

The recommendations regarding the treatment with Clopidogrel in coronary artery sugery do not take into consideration the cost-benefit ratio which reflect the usefulness from economic point of view, probably because of a the complexity of factors of this equation.
