title: Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.
abstract: OBJECTIVE
  This study sought to evaluate the impact of upstream clopidogrel in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) requiring coronary artery bypass grafting (CABG) from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.
  
  
  BACKGROUND
  Despite benefits of clopidogrel in patients with NSTE-ACS undergoing percutaneous coronary intervention, this agent is often not administered upstream (before angiography) as recommended by the American College of Cardiology/American Heart Association guidelines because of potential bleeding in the minority of patients who require CABG.
  
  
  METHODS
  The ACUITY trial enrolled 13,819 patients with NSTE-ACS undergoing early invasive management. The timing of clopidogrel initiation was per investigator discretion. A 5-day washout period before CABG was recommended for patients having received clopidogrel.
  
  
  RESULTS
  Of 13,819 patients enrolled, 1,539 (11.1%) underwent CABG before discharge. Clopidogrel-exposed patients had a longer median duration of hospitalization (12.0 days vs. 8.9 days, p < 0.0001), but fewer adverse composite ischemic events (death, myocardial infarction, or unplanned revascularization) at 30 days; 12.7% vs. 17.3%, p = 0.01), with nonsignificantly different rates of non-CABG-related major bleeding (3.4% vs. 3.2%, p = 0.87) and post-CABG major bleeding (50.3% vs. 50.9%, p = 0.83) compared with those patients not administered clopidogrel. By multivariable analysis, clopidogrel use before CABG was an independent predictor of reduced 30-day composite ischemia (odds ratio: 0.67, 95% confidence interval: 0.48 to 0.92, p = 0.001) but not of increased post-CABG major bleeding (odds ratio: 0.98, 95% confidence interval: 0.80 to 1.19, p = 0.80).
  
  
  CONCLUSIONS
  Clopidogrel administration before catheterization in patients with NSTE-ACS requiring CABG is associated with significantly fewer 30-day adverse ischemic events without significantly increasing major bleeding, compared to withholding clopidogrel until after angiography. These findings support the American College of Cardiology/American Heart Association guidelines for upstream clopidogrel administration in all NSTE-ACS patients, including those who subsequently undergo CABG. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158).
authors.affiliation: University of California Los Angeles and the Greater Los Angeles VA Medical Center, Department of Medicine, Cardiology Section (111E), Los Angeles, California 90073, USA. ebrahimi@UCLA.edu
authors.forename: Ramin
authors.initials: R
authors.lastname: Ebrahimi
authors.forename: Cornelius
authors.initials: C
authors.lastname: Dyke
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Steven V
authors.initials: SV
authors.lastname: Manoukian
authors.forename: Frederick
authors.initials: F
authors.lastname: Feit
authors.forename: David A
authors.initials: DA
authors.lastname: Cox
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Moses
authors.forename: James H
authors.initials: JH
authors.lastname: Ware
authors.forename: A Michael
authors.initials: AM
authors.lastname: Lincoff
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization / Q000379:methods*; D000077144:Clopidogrel; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods*; D003325:Coronary Care Units; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome; D014218:Triage
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine