Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis.
OBJECTIVE
The purpose of our multicenter study was to examine the impact of pre-operative administration of clopidogrel on reoperation rates, incidence of life-threatening bleeding, inpatient length of stay, and other bleeding-related outcomes in acute coronary syndrome (ACS) patients requiring cardiopulmonary bypass (coronary artery bypass graft surgery [CABG]) in a broad cross section of U.S. hospitals.


BACKGROUND
There is relative uncertainty about the relationship between clopidogrel and CABG-associated outcomes in the setting of ACS.


METHODS
A retrospective cohort analysis was performed of randomly selected ACS patients requiring CABG in 14 hospitals across the U.S. Patients exposed to clopidogrel were compared with those not exposed to clopidogrel within 5 days prior to surgery.


RESULTS
Of the 596 patients enrolled in the study, 298 had been exposed to clopidogrel within 5 days (Group A). Patients in Group A were more than 3-fold more likely to require reoperation for assessment of bleeding than patients not exposed to clopidogrel (6.4% vs. 1.7% Group B, p = 0.004). Major bleeding occurred in 35% of Group A patients versus 26% of Group B patients (p = 0.049). Length of stay was greater in Group A compared with Group B (9.7 +/- 6.0 days vs. 8.6 +/- 4.7 days, unadjusted p = 0.016). After logistic regression analysis, clopidogrel exposure within 5 days of CABG was the strongest predictor of reoperation (odds ratio [OR]: 4.60, 95% confidence interval [CI]: 1.45 to 14.55) and major bleeding (OR: 1.824, 95% CI: 1.106 to 3.008).


CONCLUSIONS
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.
Berger
Jeffrey S
JS
Division of Cardiology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina 27705, USA.
Frye
Carla B
CB
Harshaw
Qing
Q
Edwards
Fred H
FH
Steinhubl
Steven R
SR
Becker
Richard C
RC
D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D017677:Age Distribution; D000368:Aged; D000704:Analysis of Variance; D000077144:Clopidogrel; D015331:Cohort Studies; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology*; D011237:Predictive Value of Tests; D011336:Probability; D012016:Reference Values; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D018709:Statistics, Nonparametric; D015996:Survival Rate; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine