title: Optimal anticoagulation during off pump coronary artery bypass in patients recently exposed to clopidogrel.
abstract: OBJECTIVE
  The aim of this study was to find an optimal range of activated clotting time (ACT) during off-pump coronary artery bypass surgery (OPCAB) yielding ischemic protection without the risk of hemorrhagic complications in patients with recent exposure to dual antiplatelet therapy.
  
  
  METHODS
  Three hundred and five patients who received aspirin and clopidogrel within 7 days of isolated multi-vessel OPCAB were retrospectively studied. Combined hemorrhagic and ischemic outcome was defined as the occurrence of 1 of the following: significant perioperative bleeding (>30% of estimated blood volume), transfusion of packed red blood cell (pRBC) ≥ 2 U, or myocardial infarction (MI). This was compared in relation to the tertile distribution of the time-weighted average ACT-212-291 sec (first tertile), 292-334 sec (second tertile), 335-485 sec (third tertile).
  
  
  RESULTS
  The amount of perioperative blood loss was 937 ± 313 mL, 1014 ± 340 mL, and 1076 ± 383 mL, respectively (p=0.022). Significantly more patients in the third tertile developed MI (4%, 4%, and 12%, respectively, p=0.034). The incidence of significant perioperative blood loss and transfusion of pRBC ≥ 2 U were lower in the first tertile than those of other tertiles without statistical significance. In the multivariate analysis, the first tertile was associated with a 52% risk reduction of combined hemorrhagic and ischemic outcomes (95% confidence interval: 0.25-0.92, p= 0.027).
  
  
  CONCLUSIONS
  A lower degree of anticoagulation with a reduced initial heparin loading dose should be carefully considered for patients undergoing OPCAB who have recently been exposed to clopidogrel.
authors.affiliation: Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, and Severance Biomedical Science Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea.
authors.forename: Young
authors.initials: Y
authors.lastname: Song
authors.forename: Jong Wook
authors.initials: JW
authors.lastname: Song
authors.forename: Jae Kwang
authors.initials: JK
authors.lastname: Shim
authors.forename: Young Lan
authors.initials: YL
authors.lastname: Kwak
mesh_terms: D000367:Age Factors; D000368:Aged; D000714:Anastomosis, Surgical; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion; D000077144:Clopidogrel; D047549:Coronary Artery Bypass, Off-Pump; D005260:Female; D006493:Heparin / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D059035:Perioperative Period; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D011292:Premedication; D012016:Reference Values; D012189:Retrospective Studies; D012737:Sex Factors; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000627:therapeutic use; D014914:Whole Blood Coagulation Time
chemical_list: D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine
keywords: Clopidogrel; heparin; off-pump coronary artery bypass surgery; time weighted average activated clotting time
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