ANTIPLATELET THERAPY AND SECONDARY PROPHYLAXIS AFTER CORONARY BYPASS SURGERY IN ACUTE CORONARY SYNDROME
Antiplatelet therapy with aspirin and clopidogrel has clear advantages in reducing serious adverse cardiovascular events and mortality following acute coronary syndrome. Although these drugs may pose an additional risk of bleeding in the small percentage of acute coronary syndrome patients who will undergo coronary artery bypass grafting, the benefits are vastly superior, and most bleeding can be reduced, if possible, by delaying coronary artery bypass grafting. Short-acting anticoagulants can be administered flexibly, allowing platelet function to be restored after clopidogrel is discontinued. The postoperative bleeding time may clarify the need for platelet transfusion in case of bleeding. Coronary artery bypass grafting without the use of a heart- lung machine may offer some benefits by avoiding heparinization and the inflammatory response associated with bypass surgery. Secondary prophylaxis with antiplatelet therapy, beta-blockers, lipid-lowering therapy, and ACE inhibitors or angiotensin-converting enzyme inhibitors is critical to the long-term success of revascularization. In this regard, it should be borne in mind that regardless of the method of revascularization, patients with acute coronary syndrome are characterized by the clinical benefit of taking antiplatelet agents such as aspirin and clopidogrel, since these drugs reduce the risk of serious adverse events. On the other hand, antiplatelet agents also increase the risk of bleeding in patients who will eventually undergo coronary artery bypass grafting. However, scientists indicate that in most cases, the benefits of early initiation of antiplatelet therapy outweigh the potential risks [1]. In addition, the beneficial effects of aspirin and clopidogrel in acute coronary syndrome are additive. In the study of clopidogrel, indicated for the prevention of recurrence of unstable angina and non-ST-segment elevation myocardial infarction, patients taking both clopidogrel and aspirin were less likely to die of cardiac death, non-fatal myocardial infarction, or stroke at 30 days and 1 year compared with patients who took only aspirin [22]. All these studies confirm that antiplatelet therapy with aspirin and clopidogrel should be carried out in the early stages of acute coronary syndrome. In patients with ST- segment elevation myocardial infarction, clopidogrel improves outcomes in addition to aspirin. In a trial of clopidogrel and metoprolol for myocardial infarction, clopidogrel, in addition to aspirin, was associated with a significant reduction in death, re-heart attack, or stroke compared with aspirin alone [14].