Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery?: a meta-analysis.
BACKGROUND
Although aprotinin is known to be effective in reducing postoperative hemorrhage after cardiac surgery, epsilon-aminocaproic acid, an alternative antifibrinolytic, is considerably less expensive. Because the results of 3 small randomized clinical trials comparing these 2 agents directly were inconclusive, we performed a meta-analysis to compare the relative effectiveness and adverse-effect profile of these 2 agents against placebo.


RESULTS
Data from 52 randomized clinical trials published between 1985 and 1998 involving the use of epsilon-aminocaproic acid (n=9) or aprotinin (n=46) in patients undergoing cardiac surgery were abstracted. Our primary outcomes were total blood loss, red blood cell transfusion rates and amounts, reexploration, stroke, myocardial infarction, and mortality. The meta-analysis revealed substantial reductions in total blood loss with epsilon-aminocaproic acid and low-dose aprotinin (each with a 35% reduction versus placebo, P<0.001) and high-dose aprotinin (53% reduction, P<0.001). There were identical reductions in total postoperative transfusions with epsilon-aminocaproic acid (61% reduction versus placebo, P<0. 010) and high-dose aprotinin (62% reduction, P<0.001). The proportion of patients transfused was similarly reduced with epsilon-aminocaproic acid (OR, 0.32; 95% CI, 0.15 to 0.69) and high-dose aprotinin (OR, 0.28; 0.22 to 0.37). Although both drugs reduced rates of reexploration to similar degrees, this effect was statistically significant only with high-dose aprotinin (OR, 0.39; 0. 24 to 0.61). epsilon-Aminocaproic acid and aprotinin had no effect on risks of postoperative myocardial infarction or overall mortality.


CONCLUSIONS
Because the 2 antifibrinolytic agents appear to have similar efficacies, the considerably less-expensive epsilon-aminocaproic acid may be preferred over aprotinin for reducing hemorrhage with cardiac surgery.
Munoz
J J
JJ
Department of Surgery, Dartmouth Medical School, Hanover, NH, USA. john.j.munoz@hitchcock.org
Birkmeyer
N J
NJ
Birkmeyer
J D
JD
O'Connor
G T
GT
Dacey
L J
LJ
D015119:Aminocaproic Acid / Q000009:adverse effects / Q000627:therapeutic use*; D000933:Antifibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D007611:Aprotinin / Q000009:adverse effects / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D006801:Humans; D019106:Postoperative Hemorrhage / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D019616:Thoracic Surgical Procedures / Q000009:adverse effects*; D016896:Treatment Outcome
D000933:Antifibrinolytic Agents; D007611:Aprotinin; D015119:Aminocaproic Acid