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Bleeding outcomes associated with coronary artery bypass graft surgery and recent clopidogrel exposure
Danielle M Blais1, Sarah M Zukkoor, Charles Hayes
1Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA. Danielle.blais@osumc.edu
Insights
Recent clopidogrel use before coronary artery bypass graft surgery (CABG) significantly increases the risk of major bleeding. This finding supports current guidelines recommending discontinuation before the procedure.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Current guidelines suggest discontinuing clopidogrel 5 days before elective or 24 hours before urgent coronary artery bypass graft surgery (CABG).
- Conflicting evidence exists regarding clopidogrel's impact on bleeding, transfusion needs, complications, and hospital stay after CABG.
- This study evaluates the association between clopidogrel exposure within 5 days of CABG and major bleeding at a single institution.
Purpose of the Study:
- To determine if clopidogrel exposure within 5 days of CABG increases the risk of major bleeding.
- To assess secondary outcomes including non-major bleeding, postoperative complications, length of stay, readmission, and mortality.
Main Methods:
- Retrospective review of 715 patients undergoing CABG at a tertiary academic medical center.
- Primary outcome: major bleeding (≥4 units PRBCs and/or reexploration).
- Logistic regression analysis adjusted for bleeding risk factors.
Main Results:
- 169 patients (23.6%) received clopidogrel within 5 days of CABG.
- Major bleeding occurred in 32% of the clopidogrel group vs. 17% of the no-clopidogrel group (P = .002).
- Clopidogrel exposure was independently associated with higher odds of major bleeding (OR 2.1, P = .003) and increased leg site infections (3% vs. 0.2%, P = .003).
Conclusions:
- Clopidogrel exposure within 5 days of CABG is associated with a significantly increased risk of major bleeding.
- The findings support current recommendations for clopidogrel discontinuation prior to CABG.
- Increased risk of leg site infections was also noted in clopidogrel-exposed patients.
Background:
Guidelines recommend discontinuing clopidogrel for at least 5 days before elective coronary artery bypass graft surgery (CABG) to limit blood transfusions and for at least 24 hours before urgent CABG to reduce major bleeding complications. Studies have produced conflicting results regarding whether recent exposure to clopidogrel increases bleeding, the need for intraoperative and postoperative blood products, postoperative complications, and hospital length of stay. We evaluated the effect of clopidogrel exposure on major bleeding at our institution within 5 days of CABG.
Methods:
We conducted a retrospective review of patients who underwent CABG at a tertiary academic medical center. The primary outcome was major bleeding, defined as transfusion of 4 units of packed red blood cells (PRBCs) and/or a need for reexploration. Secondary outcomes included non-life-threatening bleeding, defined as transfusion of 2 units but <4 units of PRBCs; postoperative complications; hospital length of stay; readmission within 30 days of the procedure; and hospital mortality. Major bleeding events were analyzed with a logistic regression model that adjusted for covariates of bleeding risk factors.
Results:
Of the 715 patients we reviewed, 169 patients received clopidogrel within 5 days before CABG, and 546 patients did not. A significantly higher incidence of major bleeding was observed in the clopidogrel group compared with the group not exposed to clopidogrel (32% versus 17%, P = .002). After adjusting for covariates, patients exposed to clopidogrel had significantly higher odds of major bleeding (odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P = .003). The groups were similar with respect to postoperative complications, except for infection. The clopidogrel-exposed group had a significantly higher rate of leg site infections (3% versus 0.2%, P = .003).
Conclusions:
Clopidogrel exposure within 5 days of CABG is associated with an increased risk of major bleeding.
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