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Impact of clopidogrel in coronary artery bypass grafting
Lars Englberger1, Bettina Faeh, Pascal A Berdat
1Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland.
Insights
Clopidogrel use within 72 hours of coronary artery bypass grafting (CABG) increases bleeding risks and transfusion needs. Aggressive platelet correction is vital before chest closure in patients on clopidogrel.
Area of Science:
- Cardiology
- Vascular Surgery
- Pharmacology
Background:
- Clopidogrel is a standard antiplatelet agent for preventing thrombotic events after cardiac interventions like stenting.
- Increasing use of clopidogrel for conditions like aspirin intolerance, carotid, and peripheral vascular disease raises concerns for patients requiring urgent surgery.
- Platelet inhibition by clopidogrel can compromise hemostasis in emergency surgical settings.
Purpose of the Study:
- To investigate the impact of recent clopidogrel exposure on intra- and postoperative outcomes in patients undergoing isolated coronary artery bypass grafting (CABG).
- To compare bleeding complications, transfusion requirements, and re-exploration rates between patients exposed and not exposed to clopidogrel prior to CABG.
Main Methods:
- Prospective analysis of 505 consecutive patients undergoing isolated CABG.
- Comparison of two groups: clopidogrel exposure within 72 hours before surgery (n=136) versus no clopidogrel exposure (n=369).
- Exclusion criteria included emergency surgery, failed PTCA, cardiogenic shock, valvular surgery, redo-CABG, and use of glycoprotein IIb/IIIa inhibitors.
Main Results:
- Patients exposed to clopidogrel had higher rates of severe angina, recent revascularization, and prior stenting.
- Significantly increased chest tube drainage (1485 vs 780 ml, P=0.003) and higher transfusion needs (platelets, FFP) were observed in the clopidogrel group.
- The overall re-exploration rate due to bleeding was significantly higher in patients exposed to clopidogrel (5.9% vs 1.2%, P<0.01).
Conclusions:
- Clopidogrel exposure within 3 days of CABG surgery substantially elevates risks of postoperative bleeding, transfusion requirements, and re-exploration.
- Standard heparinization and anti-fibrinolytic strategies are recommended, but aggressive correction of platelet dysfunction is crucial before chest closure.
- These findings highlight the importance of managing antiplatelet therapy in patients undergoing CABG.
Objective:
Clopidogrel has become the standard of care to prevent thrombotic complications following cardiological interventions, in particular intracoronary stenting. In addition, patients with aspirin intolerance and those with carotid and peripheral vascular disease are also increasingly treated with clopidogrel. Platelet inhibition may become a concern for hemostasis in patients treated with clopidogrel who need emergency and undelayed surgery.
Methods:
We prospectively analyzed the intra- and postoperative outcome of 505 consecutive patients who underwent isolated CABG and compared two groups: those with clopidogrel exposure until 72 h prior to surgery (n = 136) with those without exposition to clopidogrel (n = 369). Patients undergoing emergency surgery because of failed PTCA and cardiogenic shock, associated valvular surgery, redo-CABG, and those with additional platelet IIb/IIIa receptor inhibitor exposure were excluded. Patients who received aspirin and/or heparin treatment prior to surgery were not excluded.
Results:
Patients who received clopidogrel had a higher prevalence of angina class III or IV (67 vs 39%, P < 0.01), received more often revascularization within 48 h (41 vs 14%, P = 0.02), and had received more frequently stenting (57 vs 13%). Chest tube drainage was significantly increased during the first 24 h following CABG in the group of patients who had clopidogrel treatment (1485 vs 780 ml, P = 0.003) These patients also required more transfusion of platelets and fresh frozen plasma. Overall re-exploration rate because of bleeding was significantly higher in the clopidogrel group (5.9 vs 1.2%, P < 0.01). Platelets transfused before chest closure had a beneficial effect on preservation of the hemostasis.
Conclusions:
Clopidogrel exposure 3 days or less prior to CABG surgery significantly increases the risk of postoperative bleeding, the need for perioperative transfusion and the incidence of re-exploration. Surgery should be performed using standard heparinization and anti-fibrinolytic strategies but aggressive correction of platelets dysfunction is required before chest closure.
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