(Circulation. 1999;99:81-89.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Is 
-Aminocaproic Acid as Effective as Aprotinin in Reducing Bleeding With Cardiac Surgery?
A Meta-Analysis
From the Departments of Surgery (J.J.M., N.J.O.B., J.D.B., L.J.D.) and Medicine (G.T.O.), Center for the Evaluative Clinical Sciences (G.T.O., J.D.B.), Dartmouth Medical School, Hanover, NH, and the VA Outcomes Group (J.J.M., J.D.B.), Veterans Affairs Medical Center, White River Junction, Vt.
Background—Although aprotinin is
known to be effective in reducing postoperative hemorrhage
after cardiac surgery, 
-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.
Methods and Results—Data from 52 randomized clinical trials
published between 1985 and 1998 involving the use of -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 -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 -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 -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). -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 -aminocaproic
acid may be preferred over aprotinin for reducing hemorrhage
with cardiac surgery.
Key Words: -aminocaproic acid • aprotinin • hemorrhage • meta-analysis • surgery
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