The Impact of Preoperative Clopidogrel on Outcomes After Coronary Artery Bypass Grafting

Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery

“…Similarly, one study of 7048 patients receiving CABG found that a preoperative clopidogrel stop interval of 3 days produced comparable rates of re-exploration for major bleeding to those obtained by a 5-day clopidogrel stop interval. 6 Further, Firanescu and colleagues found that blood loss and the use of blood products among patients stopping clopidogrel 3 days preoperatively were comparable to those discontinuing clopidogrel 5 days before surgery. 9 While we did not demonstrate a statistically significant increase in major bleeding at 2-3 days, the odds ratio was very close to unity for hemorrhagic complications (OR 1.81; 95% CI: 0.98-3.36).…”

“…12,24 Patient acuity as well as bed occupancy pressures impact the decision to minimize the duration of delay for safe surgery. 6 These factors contribute to the impetus to determine a shorter stop interval for clopidogrel before surgery while maintaining patient safety.…”

“…1-3 However, many ACS patients require in-hospital CABG, where these agents increase the risk of bleeding, reexploration, and increased transfusion rates with adverse perioperative outcomes including mortality and prolonged ventilation. [4][5][6][7][8][9][10][11][12][13][14] Clinical practice guidelines recommend a 5-day waiting period pre-operatively before CABG to reduce these risks. [18][19][20][21] While the European Society of Cardiology (ESC) stands firmly on a 5 day stop interval, the Canadian Cardiovascular Society (CCS)/Canadian Association of Interventional Cardiology (CAIC) and American Heart Association (AHA)/American College of Cardiology (ACC) weakly recommend a shorter stop interval for those requiring urgent surgical care.…”

“…18,19,21 We and others have published observational studies indicating that a shorter washout period is reasonable, with some evidence supporting that bleeding outcomes for patients with 3-day stop intervals is comparable to 5 days. 6,9,22,23 Moreover, adherence to a 5-day stop interval is uncommon in clinical practice, especially in the context of a recent ACS due to patient acuity as well as bed occupancy pressures. 6,24,25 Taken together, there is uncertainty about the necessity of a five day stop interval, an interval that may impede timely revascularization.…”

“…6,9,22,23 Moreover, adherence to a 5-day stop interval is uncommon in clinical practice, especially in the context of a recent ACS due to patient acuity as well as bed occupancy pressures. 6,24,25 Taken together, there is uncertainty about the necessity of a five day stop interval, an interval that may impede timely revascularization.…”