Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?

• Published in: European heart journal Vol. 26; no. 6; pp. 576 - 583
• Main Authors: Kapetanakis, Emmanouil I., Medlam, Diego A., Boyce, Steven W., Haile, Elizabeth, Hill, Peter C., Dullum, Mercedes K.C., Bafi, Ammar S., Petro, Kathleen R., Corso, Paul J.
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01.03.2005; Oxford Publishing Limited (England)
• Subjects: Aged; Biological and medical sciences; Blood Loss, Surgical; Blood Transfusion; Cardiology. Vascular system; Clopidogrel; Coronary Artery Bypass - mortality; Coronary artery bypass graft surgery; Coronary Disease - drug therapy; Coronary Disease - mortality; Coronary Disease - surgery; Coronary heart disease; Female; Haemostasis; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Heart; Humans; Logistic Models; Male; Medical sciences; Middle Aged; Nervous system (semeiology, syndromes); Neurology; Platelet Aggregation Inhibitors - therapeutic use; Postoperative Complications - prevention & control; Postoperative Complications - therapy; Postoperative Hemorrhage - therapy; Premedication; Prospective Studies; Re-operation due to bleeding; Reoperation; Risk Factors; Thrombosis - prevention & control; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use; Transfusion rates; Headache; Nervous system diseases; Transfusion; Rate; Transfusion rates; Cardiovascular disease; Operation; Haemostasis; Coronary heart disease; Hemorrhage; Surgeon; Pain; Treatment; Hemostasis; Surgery; Clopidogrel; Graft; Re-operation due to bleeding; Neurological disorder; Coronary artery bypass graft surgery
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehi074

Aims Thrombotic complications after percutaneous coronary intervention procedures have decreased in past years mainly due to the use of clopidogrel antiplatelet therapy. However, the risk of bleeding due to enhanced and irreversible platelet inhibition in patients who will require surgical coronary revascularization instead has not been adequately addressed in the literature. The purpose of this study was to evaluate the effect of pre-operative clopidrogel exposure in haemorrhage-related re-exploration rates, peri-operative transfusion requirements, morbidity, and mortality in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods and results A study population of 2359 patients undergoing isolated CABG between January 2000 and June 2002 was reviewed. Of these, 415 (17.6%) received clopidogrel prior to CABG surgery, and 1944 (82.4%) did not. A risk-adjusted logistic regression analysis was used to assess the association between clopidogrel pre-medication (vs. no) and haemostatic re-operation, intraoperative and post-operative blood transfusion rates, and multiple transfusions received. Haemorrhage-related pre-operative risk factors identified from the literature and those found significant in a univariate model were used. Furthermore, a sub-cohort, matched-pair by propensity scores analysis, was also conducted. The clopidogrel group had a higher likelihood of haemostatic re-operation [OR=4.9, (95% CI, 2.63–8.97), P<0.01], an increase in total packed red blood cell transfusions [OR=2.2, (95% CI, 1.70–2.84), P<0.01], multiple unit blood transfusions [OR=1.9, (95% CI, 1.33–2.75), P<0.01] and platelet transfusions [OR=2.6, (95% CI, 1.95–3.56), P<0.01]. Surgical outcomes and operative mortality [OR=1.5, (95% CI, 0.36–6.51), P=0.56] were not significantly different. Conclusion Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.