Response to Letters Regarding Article, “Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?”

Abstract

Because our initial goal was to generate interest in the hemorrhagic complications caused by the use of clopidogrel in cardiac surgery patients, it was with satisfaction that we read the comments of Poston and van der Linden et al regarding our own contribution to the discussion. 1 Both Poston and van der Linden et al propose practicable solutions to deal with the problem. They primarily advocate the perioperative administration of aprotinin as a means of reducing bleeding rates and transfusion requirements in patients exposed to clopidogrel undergoing cardiac surgery. They reach this conclusion based on previously conducted and presented research. 2,3 The widespread use of aprotinin, however, is still impeded by many surgeons' concerns about its cost, associated hypersensitivity reactions, possible thrombotic complications, and endorgan damage. 4 Although we agree that aprotinin could be used in selected high-risk patients or in cases of excessive hemorrhage (current practice at our institution), we are hesitant to advocate universal application. Furthermore, evidence in the literature regarding the safety and efficacy of aprotinin in off-pump cardiac surgery is still limited.Ideally, the best approach would be to delay the administration of clopidogrel until the coronary anatomy is deemed amenable to percutaneous coronary intervention. Otherwise, in elective circumstances, we advocate waiting 5 days before surgery in those patients who have received a loading dose of clopidogrel at the time of catheterization or who have been maintained on a daily regimen. Disclosures

2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…In the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial (359), patients in whom clopidogrel was stopped fewer than 5 days before CABG surgery had a significantly increased (9.6% versus 6.3% in the placebo arm) rate of major bleeding but no significant difference in perioperative mortality. Kapetanakis et al reported that patients receiving clopidogrel before off-pump coronary artery bypass surgery had an OR of 5.1 (95% CI 2.47 to 10.47; pϽ0.01) with regard to the need for hemostatic reoperation and a significant increase in the need for packed red blood cell and platelet transfusions but no difference in surgical mortality (360). In a series of patients undergoing carotid endarterectomy, a reduction in transcranial Doppler-determined emboli was seen with pretreatment with aspirin and clopidogrel, but no increase in bleeding complications or blood transfusions was seen (361).…”

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…In the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial (363), patients in whom clopidogrel was stopped fewer than 5 days before CABG surgery had a significantly increased (9.6% versus 6.3% in the placebo arm) rate of major bleeding but no significant difference in perioperative mortality. Kapetanakis et al reported that patients receiving clopidogrel before off-pump coronary artery bypass surgery had an OR of 5.1 (95% CI: 2.47 to 10.47, P less than 0.01) with regard to the need for hemostatic reoperation and a significant increase in the need for packed red blood cell and platelet transfusions but no difference in surgical mortality (364). In a series of patients undergoing carotid endarterectomy, a reduction in transcranial Dopplerdetermined emboli was seen with pretreatment with aspirin and clopidogrel, but no increase in bleeding complications or blood transfusions was seen (365).…”

Clopidogrel pretreatment in PCI: Absolute requirement or obsolete myth?

“…However such a strategy could delay bypass surgery -if needed -as exposure to clopidogrel within 3-5 days of surgery increases postoperative bleeding and may double the rate of reoperations according to most but not all studies [30][31][32]. Additionally, patients without significant coronary artery disease would have been exposed to aggressive clopidogrel treatment and the risk of bleeding, especially when the femoral approach is used.…”