title: Should clopidogrel be discontinued before coronary artery bypass grafting for patients with acute coronary syndrome? A systematic review and meta-analysis.
abstract: OBJECTIVE
  Patients presenting with acute coronary syndrome (ACS) are treated with dual antiplatelet agents, including aspirin and clopidogrel, to prevent mortality and recurrent ischemia. However, those who require coronary artery bypass grafting (CABG) could have increased postoperative bleeding and bleeding-related adverse outcomes. The current guidelines on clinical management differ significantly. The present meta-analysis examined the evidence for clopidogrel in the treatment of patients presenting with ACS requiring CABG, with a focus on the timing of medication cessation before surgery.
  
  
  METHODS
  A systematic review of 9 electronic databases was performed to identify all relevant studies with comparable outcomes for patients with ACS treated with clopidogrel before CABG. The endpoints included reoperation, major bleeding, mortality, and a composite endpoint of mortality and recurrent myocardial infarction.
  
  
  RESULTS
  Five relevant studies were identified according to the predefined selection criteria. Patients who had received clopidogrel had a significantly lower incidence of composite endpoints than those who had not. However, patients who underwent CABG < 5 days after the last dose of clopidogrel had a significantly greater incidence of reoperation, major bleeding, and combined adverse outcomes than those who had had a washout period >5 days.
  
  
  CONCLUSIONS
  The results from the present meta-analysis suggest that patients who present with ACS should be treated with dual antiplatelet therapy, including clopidogrel. However, for patients subsequently referred for CABG, a minimum washout period of 5 days should be observed to minimize perioperative bleeding and bleeding-related complications, unless emergency indications exist. These results differ from those of previous studies and guidelines.
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia; Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia. Electronic address: drchriscao@gmail.com.
authors: Christopher
authors: C
authors: Cao
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors: Praveen
authors: P
authors: Indraratna
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors: Su C
authors: SC
authors: Ang
authors: Department of Cardiothoracic Surgery, St George Hospital, Sydney, Australia.
authors: Con
authors: C
authors: Manganas
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors: John
authors: J
authors: Park
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
authors: Paul G
authors: PG
authors: Bannon
authors: Systematic Review Unit, Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Baird Institute for Applied Heart and Lung Surgical Research, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
authors: Tristan D
authors: TD
authors: Yan
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000175:diagnosis / Q000601:surgery*; D016009:Chi-Square Distribution; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000009:adverse effects; D004334:Drug Administration Schedule; D006801:Humans; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000517:prevention & control*; D018570:Risk Assessment; D012307:Risk Factors; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine