Otpornost na acetilsalicilnu kiselinu u kasnom poslijeoperacijskom razdoblju nakon kirurške revaskularizacije miokarda [Aspirin resistance in late postoperative period after coronary artery bypass grafting]

Study goals: In patients after coronary artery bypass grafting during the early postoperative stage there is a higher prevalence of aspirin resistance. Data concerning the issue of aspirin resistance in the late postoperative period are rare. Clinical impact of aspirin resistance has not yet been thoroughly investigated. The primary objective of this dissertation was to assess the prevalence of laboratorically defined aspirin resistance during the late postoperative period after CABG (1-6 months after the procedure) using the method of whole blood impedance aggregometry. Furthermore, by assessing primary and secondary endpoints, this study will attempt to show to which extent the laboratorically defined high on-aspirin platelet reactivity is clinically relevant with regard to major adverse cardiac events. Also we are addressing the impact of high aspirin dose on the prevalence of aspirin resistance as well as its clinical significance. Study design: Prospective monocentric randomized controlled study with 2 years follow-up period. Patients and methods: We enrolled 300 consecutive patients over 18 years old admitted to three week stationary cardiac rehabilitation after CABG meeting all the inclusion criteria: CABG 1-6 months prior to admission and antiaggregation monotherapy with ASK 100 mg daily (enteric or non-enteric form). To assess aspirin resistance we used whole blood impedance aggregometry with Multiplate® analizer (Multiple platelet function analyzer). Residual platelet activity on-aspirin treatment was measured with ASPI and TRAP test. With respect to impedance aggregometry results two groups of patients were formed: group 1 included patients with significantly depleted platelet function (aspirin sensitive patients) and group 2 included patients with high on-aspirin platelet reactivity (aspirin resistant patients). Group 2 patients were afterwards randomized in subgroup 2A (increased the dosage of ASK to 300 mg daily) and subgroup 2B (100 mg ASK daily) Upon discharge patients were contacted via telephone after a period of 6 months, one year and again after two years which was the overall follow-up period in this research. Primary end point of this study was cardiovascular death. Secondary end points were: recurrent myocardial infarction, progressive or new onset angina pectoris, recurrent myocardial revascularization (PCI or CABG), heart failure or arrhythmias which demanded hospitalization, complications of antiaggregation therapy which demanded hospitalization, stroke and overall mortality. Results: Prevalence of aspirin resistance in late postoperative phase after CABG was rather high 40, 3%. The value of ASPI test in late postoperative period in patients after CABG proved to be clinically non-significant in regard to major adverse cardiac events. Increasing the dose of ASA from 100 mg up to 300 mg daily we achieved significant reduction of repeated ASPI test values as expected (P<0,001). Repeated ASPI test values in 2B subgroup of patients at the end of cardiac rehabilitation were also significantly lower (P<0,001) in comparison with initial testing, although in absolute values still within the range of aspirin resistance. There were no statistically significant differences in aspirin resistance prevalence in regard to „on-pump“ CABG (P=0,192). In aspirin resistance group we have proven significantly higher prevalence of calcium channel blockers usage (P=0,020), NSTE myocardial infarction (P=0,007), dyslipidemia (P=0,029) statin usage (P=0,032), higher age (P=0,036) and higher BMI values (P=0,040). Statistically significant differences between two groups have also been proven in relation to number of grafts, platelet count, SDNN values and serum creatinine values. Conclusion: ASPI test results had no predictive value with respect to prevalence of major adverse cardiac events. The only independent predictor of major primary and secondary cardiovascular events was the result of TRAP test above the upper reference range limit (<151). The latter constitutes a significant scientific contribution taking into consideration the fact that there are so far no available data on TRAP test predictive value in aspirin resistant CABG patients. Patients’ compliance with respect to antiaggregation therapy is an imperative when addressing the topic of aspirin resistance prevalence. The results of our study did not reveal any significant differences in mortality or prevalence of major adverse cardiac events between two groups of patients. Whether or not to routinely test the platelet response to aspirin therapy still remains an unanswered question. Further studies including early and late postoperative period after CABG on greater number of patients using guidelines oriented antiaggregation therapy are needed in order to define more accurately the independent predictive factors of aspirin resistant CABG patients’ prognosis

Antitrombocitna terapija nakon aortokoronarnog premoštenja - neujednačenost svakodnevne kliničke prakse

Antiplatelet therapy is an integral part of optimal medicamentous therapy in patients with coronary artery disease. The strategy of antiplatelet/anticoagulant therapy is adjusted (combination of drugs, dosing and duration of therapy) depending on the stage of the disease (acute coronary syndrome with percutaneous coronary intervention, chronic coronary syndrome, or coronary surgical revascularization) and comorbidity of each patient (e.g., atrial fibrillation, left ventricular thrombus, etc.). Guidelines and clinical practice in particular are not uniform and specific regarding dual antiplatelet therapy in patients undergoing coronary artery bypass grafting, especially in the setting of chronic coronary syndrome.Sastavni dio optimalne medikamentne terapije u bolesnika s koronarnom bolešću je antitrombocitna terapija. Terapija antitrombocitnim te antikoagulantnim lijekovima (kombinacija lijekova, doziranje i trajanje terapije) prilagođava se ovisno o stadiju bolesti (akutni koronarni sindrom s perkutanom koronarnom intervencijom, kronični koronarni sindrom ili kirurška revaskularizacija) i komorbiditetu pojedinog bolesnika (npr. atrijska fibrilacija, tromb lijeve klijetke itd.). Smjernice, a osobito klinička praksa, nisu jedinstvene u pogledu dvojne antitrombocitne terapije u bolesnika koji su podvrgnuti operaciji aortokoronarnog premoštenja, naročito u postavkama kroničnog koronarnog sindroma

Utječe li tehnika zbrinjavanja dišnoga puta u uvjetima izvanbolničke hitne medicine na ishod kardiopulmonalne reanimacije?

According to current European Resuscitation Council guidelines, priorities in advanced life support in adult are chest compression with minimal interruption and early defibrillation. Endotracheal intubation is still considered the gold standard in airway management, but guidelines suggest that securing the airway be incremental, ranging from basic techniques to more complex ones. Doctors who work in pre-hospital emergency medicine teams (EMT) in Croatia usually lack sufficient education and expertise. The aim of this study was to determine whether there was a significant difference in recovery of spontaneous circulation during cardiopulmonary resuscitation (CPR) in out-of-hospital setting depending on the EMT airway management technique of choice. This retrospective analysis included data collected during a 10-year period at the Krapina-Zagorje County Emergency Medicine Institute on all patients with CPR performed by EMTs 20 minutes from initial emergency call. The airway management groups included oropharyngeal tube, i-gel supraglottic device, and endotracheal tube. There were 968 patients, mean age 70. In 74.61% of patients, the cause of arrest was of cardiac etiology. Our study did not find a statistically significant in difference of CPR success among the three groups analyzed according to the airway management technique of choice (p=0.74, χ2-test).Prema aktualnim smjernicama Europskog reanimacijskog vijeća prioriteti u naprednim mjerama održavanja života u odraslih su kompresija prsnoga koša s minimalnim prekidima i rana defibrilacija. Iako je endotrahealna intubacija zlatni standard zbrinjavanja dišnoga puta, smjernice upućuju na zbrinjavanje dišnoga puta postupno, od bazičnih tehnika zbrinjavanja dišnoga puta prema složenijim, sukladno iskustvu liječnika i učinkovitosti ventilacije. U Hrvatskoj timovi izvanbolničke hitne medicine (IBHM) najčešće uključuju mlade liječnike bez dovoljno izobrazbe i iskustva u naprednim tehnikama zbrinjavanja dišnoga puta. Cilj istraživanja bio je utvrditi postoji li razlika u oporavku spontane cirkulacije pri kardiopulmonalnoj reanimaciji (KPR) u uvjetima IBHM ovisno o izboru tehnike zbrinjavanja dišnoga puta. Retrospektivno smo analizirali podatke iz programa e-Hitna kroz desetogodišnje razdoblje u Zavodu za hitnu medicinu Krapinsko-zagorske županije. U analizu su uključeni svi bolesnici kod kojih su KPR proveli timovi IBHM unutar 20 minuta od poziva. Tehnike zbrinjavanja dišnoga puta koje su se analizirale bile su: orofaringealni tubus, i-gel maska, endotrahealni tubus. Istraživanjem je obuhvaćeno 968 ispitanika srednje dobi od 70 godina. U 74,61% ispitanika uzrok aresta bio je kardijalne etiologije. U provedenom istraživanju nije pronađena statistički značajna razlika u uspješnosti oživljavanja između tri skupine ovisno o tehnici zbrinjavanja dišnoga puta (p=0,74, χ2-test)

Heyde Syndrome – An Often-Neglected Pathophysiological Course in Daily Clinical Practice

Klasični trijas simptoma aortalne stenoze – angina pektoris, zatajivanje srca te sinkopa, kliničarima je dobro poznat, no manifestacije aortalne stenoze na druge organske sustave često ostaju neprepoznate. Angiodisplazije probavnog trakta, kao i aortalna stenoza, degenerativna su bolest, a samim time češće u starijoj populaciji. Heydeov sindrom obuhvaća trijadu aortalne stenoze, stečene koagulopatije (von Willebrandov sindrom tipa 2A) i sideropenične anemije koja nastaje kao posljedica krvarenja iz gastrointestinalnih (GI) angiodisplazija ili iz nepoznatog sijela. Stečena koagulopatija nastaje zbog degradacije multimera von Willebrandova faktora (vWf) i uzrokovana je stresom smicanja na stenotičnoj aortalnoj valvuli. Zamjena aortalne valvule dovodi do oporavka koncentracije multimera vW faktora i posljedične rezolucije gastrointestinalnoga krvarenja i sideropenične anemije. U populaciji bolesnika s aortalnom stenozom razvoj sideropenične anemije treba pobuditi sumnju na Heydeov sindrom, ali i kod bolesnika s dokazanim krvarenjem iz angiodisplazija GI trakta ili nerazjašnjenim GI krvarenjem nakon endoskopske obrade potrebno je obaviti ehokardiogram s obzirom na mogućnost postojanja aortalne stenoze.The classic triad of aortic stenosis symptoms – angina pectoris, heart failure, and syncope - is well-known among clinicians, but manifestations of aortic stenosis on other systems often remain unrecognized. Gastrointestinal (GI) angiodysplasia, like aortic stenosis, is degenerative disease and both entities are more common in older patients. Heyde syndrome refers to a triad of aortic stenosis, acquired coagulopathy (von Willebrand syndrome type 2A), and sideropenic anemia due to bleeding from gastrointestinal angiodysplasia or from an idiopathic site. Acquired coagulopathy arises from degradation of vWF multimers by the shear stress across the stenotic aortic valve. Aortic valve replacement leads to rise in vW factor multimers and ultimate resolution of gastrointestinal bleeding and sideropenic anemia. In patients with established aortic stenosis, development of iron deficiency anemia should raise the possibility of Heyde syndrome, but patients with GI bleeding with presence of angiodysplasia or failure of endoscopy to find the site of GI bleeding should also be evaluated for aortic stenosis

Stress Cardiomyopathy in a Patient with Advanced Stage Amyotrophic Lateral Sclerosis

Stres kardiomiopatija entitet je nepoznate etiologije karakteriziran prolaznom sistoličkom disfunkcijom lijeve klijetke i regionalnim poremećajima kontraktilnosti, koji upućuju na infarkt miokarda, ali bez angiografski značajne opstruktivne koronarne bolesti srca. Klinički, u bolesnika se očituje boli u prsima i/ili dispnejom, a promjene u EKG-u upućuju na akutni infarkt miokarda s elevacijom ST-segmenta. Bitan čimbenik razvoja stres kardiomiopatije povišene su razine katekolamina u plazmi kao rezultat hiperaktivnosti simpatikusa izazvane stresnim događajem. Amiotrofična lateralna skleroza (ALS) progresivna je neurodegenerativna bolest koja zahvaća gornji i donji motoneuron, a najčešće završava smrću zbog paralize mišića za disanje i respiratornog zatajenja. U bolesnika s ALSom opisane su povišene razine katekolamina i aktivnosti simpatikusa, što čini rizik za razvoj stres kardiomiopatije. U radu je prikazana bolesnica u uznapredovaloj fazi ALS-a s razvojem stres kardiomiopatije.Stress cardiomyopathy is an entity of unknown etiology characterized by transient systolic dysfunction of the left ventricle and regional wall motion abnormality which suggest myocardial infarction, but with an absence of angiographic evidence of obstructive coronary artery disease. Patients present with chest pain or/and dyspnea, while ECG changes are similar to acute myocardial infarction with ST-elevation. An important factor in the development of stress cardiomyopathy are high catecholamine levels in the blood as a result of the hyperactivity of the sympathetic nervous system caused by a stressful event. Amyotrophic lateral sclerosis (ALS) is an incurable progressive neurodegenerative disease that causes muscle weakness and ultimately ends in death due to respiratory muscle paralysis and respiratory failure. High catecholamine levels and increased sympathetic activity have been described in patients with ALS, which suggests that ALS is a risk factor for developing stress cardiomyopathy. In this article, we present a patient at an advanced stage of ALS who developed stress cardiomyopathy

Posttraumatic Stress Disorder after Acute Coronary Syndrome or Cardiac Surgery; Underestimated Reality

Osim somatskih posljedica akutnoga koronarnog sindroma u obliku različitoga stupnja intolerancije napora, radne nesposobnosti, simptoma kroničnog srčanog zatajivanja, angine pektoris, pojave različitih aritmija i sl., moguć je već u ranoj subakutnoj te u kroničnoj fazi u oboljelih osoba razvoj niza psihosomatskih i psihičkih poremećaja, koji, ako se ne prepoznaju navrijeme i aktivno ne liječe, mogu pridonijeti nepovoljnom ishodu i povećanoj smrtnosti takve skupine bolesnika. Osim povezanosti akutnoga koronarnog sindroma i kroničnog stresa, anksioznosti i depresije, on može biti „okidač“ za razvoj kasnijega posttraumatskoga stresnog poremećaja (PTSP) sa stopom prevalencije od prosječno 15-ak posto među oboljelim osobama. Više je istraživanja pokazalo da bolesnici sa simptomima PTSP-a povezanog s prethodnim akutnim koronarnim sindromom, napose oni neliječeni, imaju povećanu smrtnost i veću stopu reinfarkta miokarda. Budući da PTSP povezan s akutnim koronarnim sindromom ili kardiokirurškom operacijom zna biti zanemaren i podcijenjen, svrha je ovog rada podizanje svijesti o ovom problemu u svakodnevnoj kliničkoj praksi.In addition to the somatic consequences of acute coronary syndrome (ACS) that include different levels of intolerance to exertion, incapacity for work, symptoms of chronic heart failure, angina pectoris, the manifestation of various arrhythmias, etc., the development of a whole range of psychosomatic and mental disorders is also possible already in the early subacute and chronic phases of the disease, and if these mental disorders are not actively treated in a timely fashion they can contributed to unwanted outcomes and increased mortality in this group of patients. ACS is associated with chronic stress, anxiety, and depression and can be a trigger for later development of posttraumatic stress disorder (PTSD) with an average prevalence rate of 15% in patients with ACS. Several studies have shown that patients with symptoms of PTSD associated with ACS, especially if untreated, have increased mortality and higher rates of myocardial reinfarction. Since PTSD associated with ACS or cardiac surgery can be neglected or underestimated, the aim of this review was to raise awareness about this issue that is present in everyday clinical practice

Aspirin resistance in late postoperative period after coronary artery bypass grafting

Cilj istraživanja: Poznato je da u ranoj poslijeoperacijskoj fazi nakon kardiokirurške revaskularizacije miokarda postoji povećana prevalencija aspirinske rezistencije u odnosu na vrijednosti prije operacije. Podaci o učestalosti ASK rezistencije u kasnijoj poslijeoperacijskoj fazi te njenom prognostičkom značenju su rijetki. Cilj ovog istraživanja bio je metodom impedancijske agregometrije ustanoviti kolika je učestalost laboratorijski dokazane aspirinske rezistencije tijekom kasne postoperativne faze u bolesnika nakon aortokoronarnog premoštenja (između 1-6 mjeseci nakon kirurškog zahvata). Studija je kroz primarne i sekundarne točke praćenja nastojala pokazati i u kojem je opsegu laboratorijski dokazana aspirinska rezistencija klinički relevantna glede pojavnosti kasnijih velikih neželjenih kardiovaskularnih događaja. Isto tako željeli smo utvrditi kakav je utjecaj povećanja doze ASK na prevalenciju aspirinske rezistencije kao i na klinički ishod aspirin rezistentnih bolesnika. Dizajn studije: prospektivna monocentrična randomizirana kontrolirana studija s vremenom praćenja od dvije godine. Bolesnici i metode: U istraživanje je uključeno 300 bolesnika starijih od 18 godina nakon učinjene kirurške revaskularizacije miokarda, unutar 1-6 mjeseci od dana operativnog zahvata na terapiji ASK u dozi od 100 mg dnevno (enterički ili ne-enterički oblik lijeka). Za procjenu rezidualne aktivacije trombocita uz terapiju ASK korištena je metoda impedancijske agregometrije iz pune krvi pomoću aparata Multiplate® analizator (ASPI test i TRAP test). Obzirom na nalaz agregometrije formirane su dvije skupine bolesnika: aspirin osjetljivi (skupina 1) te aspirin rezistentni (skupina 2). Bolesnici iz skupine 2 randomizirani su u podskupine 2A (povećana doza ASK na 300 mg) te 2B (nastavak terapije ASK 100 mg). Po otpustu kući bolesnici su kontaktirani telefonskim putem nakon 6 mjeseci, godinu dana te dvije godine, što je bilo konačno trajanje vremena praćenja u ovom istraživanju. Primarna točka praćenja bila je smrt kardiovaskularnog uzroka. Sekundarne točke praćenja bile su: ponovljeni infarkt miokarda, novonastala ili progresivna angina pektoris, ponovna revaskularizacija miokarda (PCI ili kardiokirurški zahvat), srčano popuštanje ili srčane aritmije koje zahtijevaju hospitalizaciju, komplikacije antiagregacijske terapije koje zahtijevaju bolničko liječenje, moždani udar te ukupna smrtnost. Rezultati: Učestalost aspirinske rezistencije u kasnoj poslijeoperacijskoj fazi nakon CABG bila je razmjerno visokih 40,3%. Vrijednost ASPI testa u kasnoj poslijeoperacijskoj fazi u bolesnika nakon CABG nije bila klinički značajna glede pojavnosti kasnijih velikih neželjenih kardiovaskularnih događaja. Povišenjem doze ASK na 300 mg dnevno u 2A skupini bolesnika postignuto je očekivano statistički značajno sniženje vrijednosti ponovljenog ASPI testa (P<0,001). Vrijednosti ponovljenog ASPI testa u 2B skupini bolesnika pred kraj rehabilitacijskog programa bile su statistički značajno manje (p<0,001) nego pri inicijalnom testiranju iako u apsolutnim vrijednostima ipak i dalje u rasponu vrijednosti koja se klasificirana kao aspirinska rezistencija. Nije bilo statistički značajnih razlika u incidenciji aspirinske rezistencije ovisno o upotrebi stroja za izvantjelesni krvotok (P=0,192). U skupini aspirin rezistentnih bolesnika dokazali smo statistički značajno veću učestalost uzimanja antagonista kalcijskih kanala (P=0,020), pojavnost NSTE infarkta miokarda (P=0,007), dijagnoze dislipidemije (P=0,029) i sukladno tome uzimanja statina (P=0,032), višu dob (P=0,036) i veći BMI (P=0,040). Statistički značajne razlike među skupinama dokazane su i u odnosu na broj premosnica, broj trombocita, vrijednost SDNN-a i vrijednosti serumskog kreatinina. Zaključak: Rezultati ASPI testa nisu pokazali statistički značajnu prediktivnu vrijednost glede pojavnosti velikih neželjenih događaja. Jedini nezavisni prediktor nastanka neželjenih primarnih i sekundarnih kardiovaskularnih događaja bio je rezultat TRAP testa iznad gornjih granica referentnih vrijednosti (>151) što smatramo značajnim znanstvenim doprinosom obzirom na činjenicu da literaturni podaci na temu prediktivne vrijednosti TRAP testa u kontekstu aspirin rezistentnog CABG bolesnika za sada ne postoje. Kontinuirana edukacija bolesnika o važnosti redovitog uzimanja antiagregacijske terapije od neupitne je važnosti za smanjenje učestalosti rezistencije na aspirin. Obzirom da rezultati ove studije na uzorku od gotovo 300 bolesnika u vremenu praćenja od dvije godine ne pokazuju statistički značajne razlike u smrtnosti ili pojavnosti neželjenih kardiovaskularnih događaja među ispitivanim skupinama bolesnika pitanje potrebe rutinske laboratorijske kontrole učinka ASK na agregaciju trombocita i dalje ostaje neodgovorenim. Potrebne su dodatne studije koje bi obuhvaćale veći broj bolesnika, uključivale i ranu i kasnu poslijeoperacijsku fazu nakon CABG uz medikamentnu antiagregacijsku terapiju prema važećim smjernicama, kako bi točnije definirali neovisni prediktivni čimbenici vezani uz prognozu aspirin rezistentnog CABG bolesnika.Study goals: In patients after coronary artery bypass grafting during the early postoperative stage there is a higher prevalence of aspirin resistance. Data concerning the issue of aspirin resistance in the late postoperative period are rare. Clinical impact of aspirin resistance has not yet been thoroughly investigated. The primary objective of this dissertation was to assess the prevalence of laboratorically defined aspirin resistance during the late postoperative period after CABG (1-6 months after the procedure) using the method of whole blood impedance aggregometry. Furthermore, by assessing primary and secondary endpoints, this study will attempt to show to which extent the laboratorically defined high on-aspirin platelet reactivity is clinically relevant with regard to major adverse cardiac events. Also we are addressing the impact of high aspirin dose on the prevalence of aspirin resistance as well as its clinical significance. Study design: Prospective monocentric randomized controlled study with 2 years follow-up period. Patients and methods: We enrolled 300 consecutive patients over 18 years old admitted to three week stationary cardiac rehabilitation after CABG meeting all the inclusion criteria: CABG 1-6 months prior to admission and antiaggregation monotherapy with ASK 100 mg daily (enteric or non-enteric form). To assess aspirin resistance we used whole blood impedance aggregometry with Multiplate® analizer (Multiple platelet function analyzer). Residual platelet activity on-aspirin treatment was measured with ASPI and TRAP test. With respect to impedance aggregometry results two groups of patients were formed: group 1 included patients with significantly depleted platelet function (aspirin sensitive patients) and group 2 included patients with high on-aspirin platelet reactivity (aspirin resistant patients). Group 2 patients were afterwards randomized in subgroup 2A (increased the dosage of ASK to 300 mg daily) and subgroup 2B (100 mg ASK daily) Upon discharge patients were contacted via telephone after a period of 6 months, one year and again after two years which was the overall follow-up period in this research. Primary end point of this study was cardiovascular death. Secondary end points were: recurrent myocardial infarction, progressive or new onset angina pectoris, recurrent myocardial revascularization (PCI or CABG), heart failure or arrhythmias which demanded hospitalization, complications of antiaggregation therapy which demanded hospitalization, stroke and overall mortality. Results: Prevalence of aspirin resistance in late postoperative phase after CABG was rather high 40, 3%. The value of ASPI test in late postoperative period in patients after CABG proved to be clinically non-significant in regard to major adverse cardiac events. Increasing the dose of ASA from 100 mg up to 300 mg daily we achieved significant reduction of repeated ASPI test values as expected (P<0,001). Repeated ASPI test values in 2B subgroup of patients at the end of cardiac rehabilitation were also significantly lower (P<0,001) in comparison with initial testing, although in absolute values still within the range of aspirin resistance. There were no statistically significant differences in aspirin resistance prevalence in regard to „on-pump“ CABG (P=0,192). In aspirin resistance group we have proven significantly higher prevalence of calcium channel blockers usage (P=0,020), NSTE myocardial infarction (P=0,007), dyslipidemia (P=0,029) statin usage (P=0,032), higher age (P=0,036) and higher BMI values (P=0,040). Statistically significant differences between two groups have also been proven in relation to number of grafts, platelet count, SDNN values and serum creatinine values. Conclusion: ASPI test results had no predictive value with respect to prevalence of major adverse cardiac events. The only independent predictor of major primary and secondary cardiovascular events was the result of TRAP test above the upper reference range limit (<151). The latter constitutes a significant scientific contribution taking into consideration the fact that there are so far no available data on TRAP test predictive value in aspirin resistant CABG patients. Patients’ compliance with respect to antiaggregation therapy is an imperative when addressing the topic of aspirin resistance prevalence. The results of our study did not reveal any significant differences in mortality or prevalence of major adverse cardiac events between two groups of patients. Whether or not to routinely test the platelet response to aspirin therapy still remains an unanswered question. Further studies including early and late postoperative period after CABG on greater number of patients using guidelines oriented antiaggregation therapy are needed in order to define more accurately the independent predictive factors of aspirin resistant CABG patients’ prognosis