Impact of Clopidogrel Stop Interval on Major Adverse Bleeding Events in Cardiac Surgery
Bright Huo1, Gregory M Hirsch2, Steve Doucette2
1Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Insights
Stopping clopidogrel 3-4 days before cardiac surgery is safe, with no increased bleeding risk. However, stopping 1-2 days before surgery significantly increases transfusion and bleeding complications.
Area of Science:
- Cardiology
- Cardiothoracic Surgery
- Pharmacology
Background:
- Current guidelines recommend a 5-day clopidogrel cessation before cardiac surgery.
- High-acuity patient presentations often lead surgeons to use shorter clopidogrel stop intervals.
- This study investigates the impact of clopidogrel cessation timing on bleeding events.
Purpose of the Study:
- To determine the effect of clopidogrel cessation duration on adverse bleeding events in cardiac surgery patients.
- To evaluate the safety of shorter clopidogrel stop intervals.
Main Methods:
- Retrospective cohort study of 5748 cardiac surgery patients (2009-2016).
- Multivariable logistic regression analysis adjusted for clopidogrel stop interval, age, procedure urgency, and type.
- Outcomes assessed included massive transfusion and hemorrhagic complications.
Main Results:
- 30.3% of patients received clopidogrel preoperatively; 50.7% stopped it 5 days prior.
- Clopidogrel use 1-2 days before surgery independently predicted massive transfusions (OR 1.97) and hemorrhagic complications (OR 1.85).
- A 3-4 day clopidogrel stop interval showed no increased risk of major bleeding.
Conclusions:
- A 3-4 day clopidogrel stop interval is not associated with increased major bleeding risk.
- Shorter intervals (1-2 days) significantly increase bleeding risks.
- Surgery urgency and complexity also correlate with increased bleeding risk.
Background:
Major societal guidelines recommend a 5-day stop interval before cardiac surgery for patients with acute coronary syndrome receiving clopidogrel. Yet, many such patients present with high acuity, generating surgeon inclination toward use of shorter stop intervals. Thus, this study aimed to determine the impact of the duration and timing of the interval of clopidogrel cessation on adverse bleeding events.
Methods:
Patients who underwent cardiac surgery between 2009 and 2016 at a tertiary-care centre were included in this retrospective cohort study. Multivariable logistic regression models adjusted for clopidogrel stop interval, age, urgency of procedure, and procedure type were used to quantify the effect of clinically relevant baseline demographic characteristics on incidence of massive transfusion as well as hemorrhagic complication outcomes.
Results:
A total of 5748 patients underwent cardiac surgery. In this cohort, 1743 patients (30.3%) received clopidogrel preoperatively, and 884 (50.7%) of these patients discontinued clopidogrel 5 days before presenting to the operating room. The administration of clopidogrel 1-2 days before surgery (odds ratio 1.97; 95% confidence interval: 1.18 to 3.29) was an independent predictor for massive transfusions and hemorrhagic complications (odds ratio 1.85; 95% confidence interval: 1.01 to 3.37). The 3-4 day group did not have an increased risk of major bleeding complications. The risk for both massive transfusions and hemorrhagic complications also increased with the urgency and complexity of surgery.
Conclusion:
A clopidogrel stop interval of 3-4 days preoperatively was not associated with an increased risk for major bleeding complications.
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