Aprotinin and CABG
The majority of patients undergoing cardiovascular surgery routinely receive antifibrinolytic therapy - aminocaproic acid, tranexamic acid or aprotinin during and after procedure to control bleeding. In last couple of years, use of aprotinin has been questioned following coronary artery bypass grafting, particularly in view of availability of safer and less expensive alternatives ie aminocaproic acid and tranexamic acid.
One major article published last year in The New England Journal of Medicine concluding that the use of aprotinin was associated with a dose-dependent doubling to tripling in the risk of renal failure requiring dialysis among patients undergoing primary or complex coronary-artery surgery. Also, it was suggested that for the majority of patients undergoing primary surgery, evidence of multiorgan damage involving the heart (myocardial infarction or heart failure) and the brain (encephalopathy) in addition to the kidneys shows a generalized pattern of ischemic injury 1.
Same group, published an article this week in JAMA 2, looked into mortality data of 3876 patients from 62 medical centers assessed at 6 weeks, 6 months, and annually for 5 years after CABG surgery.
Study contrast 3 groups
- aminocaproic acid and tranexamic acid,
- aprotinin, or
- no antibleeding agent (control)
Study found that Aprotinin treatment was associated with significantly increased long term mortality compared with control, whereas neither aminocaproic acid nor tranexamic acid was associated with increased mortality.
Note: FDA has issued a relabeling of aprotinin on December 15, 2006, confining it to use only in high-risk coronary artery bypass graft patients.
Previous related pearl: Should we abandon Aprotinin ?
References / suggested readings: Click to get article/abstract
1. The Risk Associated with Aprotinin in Cardiac Surgery - NEJM Jan. 26, 2006 Volume 354:353-365
2. Mortality Associated With Aprotinin During 5 Years Following Coronary Artery Bypass Graft Surgery - JAMA. 2007;297:471-479, Vol. 297 No. 5, February 7, 2007 - full text is available free
