title: Perioperative management of clopidogrel therapy: the effects on in-hospital cardiac morbidity in older patients with hip fractures.
abstract: BACKGROUND
  Increasing numbers of older patients prescribed clopidogrel are presenting for urgent hip fracture surgery. Best practice for the management of clopidogrel therapy is unknown, although delays to surgery are associated with increased mortality. We investigated the influence of perioperative management of clopidogrel therapy on in-hospital cardiac morbidity and transfusion in this population.
  
  
  METHODS
  Retrospective review of all patients aged >60 yr, admitted to a single centre with hip fractures between June 2005 and November 2008. Acute coronary syndrome (ACS) was defined as a raised plasma troponin concentration >0.04 µg litre(-1) associated with chest pain, new ECG changes, or both.
  
  
  RESULTS
  Of 1381 patients admitted with hip fractures, 114 were receiving regular clopidogrel therapy with a median age of 83.7 (60-98) yr. Clopidogrel was withheld perioperatively in 111 (98%) of these patients. Twenty-three patients (20.2%) suffered an ACS. Risk peaked for ACS [odds ratio (OR) 6.7 (95% confidence interval, CI, 1.7-25.8)] (P=0.006) between days 4 and 8 after clopidogrel withdrawal. The OR for requiring a blood transfusion during or after surgery peaked at day 1 after clopidogrel withdrawal [OR 2.31 (95% CI, 1.02-5.21)] (P=0.044).
  
  
  CONCLUSIONS
  The length of withdrawal of clopidogrel therapy perioperatively was associated with a significantly increased incidence of ACS. An association between shorter withdrawal and increased blood transfusion requirements was also seen. The study emphasizes the cardiovascular risks of routinely interrupting clopidogrel therapy in this at-risk population and that a more considered, individualized, evidenced-based approach is needed.
authors.affiliation: Department of Anaesthesia, Harrogate District Hospital, Harrogate, UK. thomascollyer@gmail.com
authors.forename: T C
authors.initials: TC
authors.lastname: Collyer
authors.forename: H C
authors.initials: HC
authors.lastname: Reynolds
authors.forename: E
authors.initials: E
authors.lastname: Truyens
authors.forename: L
authors.initials: L
authors.lastname: Kilshaw
authors.forename: T
authors.initials: T
authors.lastname: Corcoran
mesh_terms: D054058:Acute Coronary Syndrome / Q000453:epidemiology*; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D000077144:Clopidogrel; D005260:Female; D006620:Hip Fractures / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D019990:Perioperative Care; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D012189:Retrospective Studies; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine