Impact of Clopidogrel in Patients With Acute Coronary Syndromes Requiring Coronary Artery Bypass Surgery

Berger, Jeffrey S.; Frye, Carla B.; Harshaw, Qing; Edwards, Fred H.; Steinhubl, Steven R.; Becker, Richard C.

doi:10.1016/j.jacc.2008.08.031

Cited by 179 publications

(98 citation statements)

References 31 publications

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“…21, 22 As a consequence, several studies have analyzed the impact of preoperative clopidogrel on hemorrhagic complications. [4][5][6][7][8][9][10][11][12] The present data confirm that preoperative clopidogrel was an independent predictor for transfusion of blood products, supporting the discontinuation of clopidogrel >5 days before surgery in order to avoid the risk of transfusion. The present data confirm the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, which certainly endorse the acute use of clopidogrel, recommending its withholding for at least 5 days before CABG surgery.…”

Section: Discussionsupporting

confidence: 81%

Optimal Timing of Discontinuation of Clopidogrel and Risk of Blood Transfusion After Coronary Surgery - Propensity Score Analysis -

Mariscalco

Bruno

Cottini

et al. 2011

Circ J

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Section: Discussionsupporting

confidence: 81%

Optimal Timing of Discontinuation of Clopidogrel and Risk of Blood Transfusion After Coronary Surgery - Propensity Score Analysis -

Mariscalco

Bruno

Cottini

et al. 2011

Circ J

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“…The absolute bleeding risk is increased by up to 9% in some registries, [20] with an absolute increase of the risk of reoperation for bleeding of 1.5-4% [20]. However, the mortality is not increased.…”

Section: Clopidogrelmentioning

confidence: 99%

Antiplatelet and Anticoagulant Therapies in Acute Coronary Syndromes

Hanna

Glancy

Saucedo

2009

Cardiovasc Drugs Ther

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The combination of aspirin and clopidogrel is the mainstay antiplatelet therapy for acute coronary syndromes (ACS). However, the dosing of aspirin, the dosing of clopidogrel, the timing of clopidogrel initiation as well as the duration of clopidogrel therapy remain controversial matters. Clopidogrel resistance is an emerging concept with potential clinical implications. In the era of clopidogrel and bivalirudin, the role of glycoprotein IIb/IIIa antagonists is being challenged, yet they are still indicated in a select high-risk population. Concerning anticoagulant use in ACS, newer agents, bivalirudin and fondaparinux, have improved outcomes in comparison to heparin in patients managed with an invasive or conservative strategy, respectively. Combining multiple antiplatelet agents and an anticoagulant is the standard of care for ACS.

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“…It is hard to know before angiography which patients will be referred for CABG [11]. There is a high incidence of major bleeding complications in patients treated with CABG fewer than 5 days before discontinuing clopidogrel [12][13][14][15]. As long as CABG is delayed at least 5 days after the last clopidogrel dose (as in the majority of patients in the CURE trial [7] and as the Society of Thoracic Surgery guidelines [5] recommend), patients may receive clopidogrel upstream.…”

Section: Adp Receptor Antagonistsmentioning

confidence: 99%

Balancing the benefits and risks of antiplatelet agents in patients with non-ST-segment elevated acute coronary syndromes and undergoing percutaneous coronary intervention

Saucedo

2010

J Thromb Thrombolysis

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Selecting appropriate antiplatelet therapy requires close attention to the delicate balance between reducing risk of ischemic events while minimizing bleeding risk. The broad range of available agents, while permitting tailoring of pharmacotherapy to individual patients, also complicates selection of optimal regimens. Platelet physiology provides an underpinning for the rationale behind pharmacotherapeutic strategies for patients with non-ST-segment elevated acute coronary syndromes (NSTE ACS) undergoing percutaneous coronary intervention (PCI). The same mechanisms of action that confer anti-ischemic benefit with antiplatelet agents may also be associated with increased risk. In the context of ACS and PCI, antiplatelet agents are used in complex strategies and combinations with other pharmacotherapies targeted at alleviating ischemic symptoms and reducing ischemic risk. Accounting for individual patient risk factors, timing of treatment, and dosage of antiplatelet medications minimizes risk while optimizing outcomes. This review examines results from clinical trials of thienopyridines (clopidogrel, ticlopidine, and the newer prasugrel), the new P2Y(12) antagonists ticagrelor and cangrelor, glycoprotein IIb-IIIa inhibitors (abciximab, eptifibatide, tirofiban), and the direct thrombin inhibitor bivalirudin. Recommendations include clopidogrel for use upstream if discontinued 5 days before coronary angiographic bypass graft. Bivalirudin remains a reasonable treatment choice in patients at low to moderate risk; and glycoprotein IIb-IIIa inhibitors confer anti-ischemic benefit with little incremental bleeding risk when individual patient factors are taken into account for their dosing. Increased awareness of the factors contributing to risks and benefits associated with the available antiplatelet agents will help guide physicians in choosing optimal regimens for all patients.

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Impact of Clopidogrel in Patients With Acute Coronary Syndromes Requiring Coronary Artery Bypass Surgery

Abstract: After ACS, patients who undergo CABG within 5 days of receiving clopidogrel are at increased risk for reoperation, major bleeding, and increased length of stay. These risks must be balanced by the clinical benefits of clopidogrel use demonstrated in randomized clinical trials.

Cited by 179 publications

References 31 publications

Optimal Timing of Discontinuation of Clopidogrel and Risk of Blood Transfusion After Coronary Surgery - Propensity Score Analysis -

Optimal Timing of Discontinuation of Clopidogrel and Risk of Blood Transfusion After Coronary Surgery - Propensity Score Analysis -

Antiplatelet and Anticoagulant Therapies in Acute Coronary Syndromes

Balancing the benefits and risks of antiplatelet agents in patients with non-ST-segment elevated acute coronary syndromes and undergoing percutaneous coronary intervention

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