Effects of Continuous Administration of Clopidogrel Before Off-Pump Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome A Propensity Score Analysis

Abstract

Background Clopidogrel has become standard treatment after urgent percutaneous coronary revascularization. Due to its enhanced and irreversible platelet inhibition, patients undergoing urgent surgical revascularization have a higher risk of bleeding complications and transfusions. Therefore, the effect of preoperative continuous administration of clopidogrel on the incidence of hemorrhagic complications in patients undergoing off-pump coronary artery bypass surgery with acute coronary syndrome was evaluated. Methods and ResultsFrom March 2004 to September 2006, 172 patients with acute coronary syndrome underwent isolated off-pump coronary artery bypass surgery; 70 (40.7%) and 102 (59.3%) of these patients did or did not take clopidogrel before surgery respectively. Seventy patients in each group were matched using propensity scores and associations between preoperative continuous administration of clopidogrel and postoperative bleeding, hemostatic reoperation, blood products received, the need for multiple transfusions and early graft patency by coronary computed tomography were assessed. Univariate analysis showed the continuous clopidogrel group had similar levels of postoperative bleeding for 24 h (601.4±312.6 ml vs 637.2±452.4 ml, p=0.616) and rates of reexploration (1.4% vs 1.4%), perioperative blood transfusion (33.3% vs 34.3%, p>0.05) and platelet transfusion (2.9% vs 7.1%, p=0.44) compared with the non-continuous group. Conclusions Preoperative continuous administration of clopidogrel did not increase the risk of hemorrhagic complications in patients with acute coronary syndrome undergoing isolated off-pump coronary artery bypass surgery. These findings indicate that surgery after clopidogrel treatment in patients with acute coronary syndrome should not be delayed until platelet function returns to normal because they may have a higher risk of recurrent myocardial ischemic events. (Circ J 2008; 72: 626 -632)

Non-cardiac surgery and antiplatelet therapy following coronary artery stenting

“…Other data show similar findings to those of the CURE study, demonstrating that rates of intraoperative blood loss, postoperative chest drain blood loss, reoperation for bleeding and requirement for transfusion are consistently found to be higher in patients receiving clopidogrel,21 with occasional exceptions 22…”

Impact of preoperative dual antiplatelet therapy on bleeding complications in patients with acute coronary syndromes who undergo urgent coronary artery bypass grafting

“…The performance of off-pump CABG by an experienced surgeon may reduce bleeding, if urgent operation is required within 5 days after discontinuing treatment with clopidogrel. In Korean patients with ACS who underwent isolated off-pump CABG, preoperative administration of clopidogrel did not increase the risk of death or hemorrhagic complications [24]. In the present study, the intraoperative bleeding volume and the total drain output within 48 h after surgery were similar in the DAPT group and SAPT group, suggesting a high level of surgical expertise and effective use of hemostatic procedures.…”

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

“…3-6 By avoiding CPB, off-pump coronary artery bypass surgery (OPCAB) is associated with less deterioration in coagulation and has been suggested as an alternative surgical technique to CPB in patients exposed to recent antiplatelet therapy, mitigating perioperative blood loss while maximizing ischemic benefit. [7][8][9][10] Colloids are often used in cardiac surgery because colloids are more efficient than crystalloids in maintaining intravascular volume and osmotic pressure, and improving microperfusion. 11- 16 Hydroxyethyl starch (HES) solutions, however, the most widely used synthetic colloids, cause adverse effects on coagulation that are mainly attributable to the mean molecular weight and degree of substitution.…”