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


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.


CONCLUSIONS
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.
Kapetanakis
Emmanouil I
EI
Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 106 Irving Street, NW, Suite 316, Washington, DC 20010-2975, USA. emmanouil_kapetanakis@yahoo.com
Medlam
Diego A
DA
Boyce
Steven W
SW
Haile
Elizabeth
E
Hill
Peter C
PC
Dullum
Mercedes K C
MK
Bafi
Ammar S
AS
Petro
Kathleen R
KR
Corso
Paul J
PJ
D000368:Aged; D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000401:mortality; D003327:Coronary Disease / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011183:Postoperative Complications / Q000517:prevention & control / Q000628:therapy; D019106:Postoperative Hemorrhage / Q000628:therapy; D011292:Premedication; D011446:Prospective Studies; D012086:Reoperation; D012307:Risk Factors; D013927:Thrombosis / Q000517:prevention & control; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use*
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine