Ann Thorac Surg 2000;70:S42
© 2000 The Society of Thoracic Surgeons
Discussion
DR LEVY: Are there any questions for Dr LeNarz while he has his data out?
QUESTION FROM THE AUDIENCE: I would like to make one point. In the EPISTENT group in particular, the interventionists were told to treat all patients presuming they were going to get stents. And it turned out about that 60% of the patients were pretreated with ticlopidine. So about 40% of the patients who ended up not getting stents had received ticlopidine. And there are institutions in which 3 days of ticlopidine therapy before the intervention was not unusual, which could dramatically affect the bleeding risk. So I do not know if the case report form looked at that and the duration of prior ticlopidine therapy. But with such a small number of patients, if three of them happened to be ticlopidine-pretreated patients, there would have been a significant effect on the bleeding rate, especially when compared with placebo patients or to EPILOG patients, the vast majority of whom, I am certain, did not get ticlopidine.
DR LENARZ: Because I am a representative of the sponsor, I would not want anyone to interpret my comments as negative toward ticlopidine. We all know what ticlopidine has meant for stented patients. And we know that the acceptance of stent use has been, in large part, because of lowering event rates with ticlopidine combined with aspirin. But I think the purpose of this meeting is to help us understand these drugs and what interactions with them could mean. I was surprised to see, as we broke it down, that all of those patients were transfused. I doubt we will be able to tell exactly when they got their ticlopidine or how it affected their surgery. However, I think that there may be a need for a point-of-care type of analysis or some other means of identifying which patients need to be transfused because of multiple drugs inhibiting different aspects of aggregation.
I truly believe that surgeons know bleeding. They know when they can close. They have operated on thousands of cases and they have a sixth sense that tells them when their field is dry and when it is not. But I think we must be aware of impaired platelet function resulting from ASA, ticlopidine, and abciximab. I do not know if the lack of reversibility by ASA and ticlopidine is what creates the additional blood loss.
QUESTION FROM THE AUDIENCE: I agree with that entirely. I think it is important to glean from the data what drugs they received. In addition, I wonder how many of these patients received aspirin.
DR LENARZ: More than 90% of patients received aspirin. But the important message to be gleaned is that the abciximab effect is reversible with platelet transfusion.
Related Article
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Group recommendations
- Jerrold H. Levy, Peter K. Smith, Leroy A. LeNarz, John H. Lemmer, Jr, Steven R. Steinhubl, George J. Despotis, and Lawrence T. Goodnough
Ann. Thorac. Surg. 2000 70: S43.
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