Bleeding-associated outcomes with preoperative clopidogrel use in on- and off-pump coronary artery bypass

Abstract

Clopidogrel use prior to coronary artery bypass graft surgery in patients presenting with acute coronary syndromes is associated with a greater incidence of procedural related morbidity. We studied the impact of clopidogrel pre-treatment in patients undergoing off-pump versus on-pump coronary revascularization. This report describes a post hoc analysis of 431 on-pump and 165 off-pump cases from a retrospective multicenter study of the impact of preoperative (within 5 days) clopidogrel use on bleeding related outcomes and surgical reintervention. Logistic regression was used to analyze the outcomes with respect to surgery type and clopidogrel exposure while using a propensity score risk adjustment for off-pump surgery. The hospital length of stay (9.3 ± 5.4 days vs. 8.9 ± 5.3 days, p = 0.35), major bleeding (21% vs. 20%, p = 0.74) and reoperation (3.7% vs. 4.8%, p = 0.53) were similar between on-pump and off-pump, respectively. In both surgical cohorts, recent clopidogrel use was associated with a greater incidence of major bleeding, reoperation, and transfusion. After multivariable adjustment, the odds ratio of major bleeding (1.76, 95% confidence interval 0.88-3.52 on-pump; 2.37, 95% confidence interval 1.06-5.30 off-pump) and reoperation (4.52, 95% confidence interval 0.58-36.6 in on-pump; 7.05, 95% confidence interval 0.82-60.5 in off-pump) was increased in clopidogrel-treated patients compared to no clopidogrel. Major bleeding and reoperation did not differ significantly between patients undergoing on- or off-pump surgery. Clopidogrel treatment within 5 days prior to surgery increased the risk of bleeding and reoperation in all CABG patients irrespective of whether surgery was performed on- or off-pump.

Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery

“…24,26,54 In a study of 4330 patients undergoing CABG, those on clopidogrel plus aspirin within 5 and 2 days before surgery, respectively, were found to experience higher blood loss and reoperation for bleeding. 55 This finding seems consistent irrespective of whether surgery is performed on-or off-pump 56,57 and is likely to be sensitive to the loading dose administered. 58 A systematic review of post hoc analyses from 3 prospective randomized studies and 17 observational studies yielded mixed results.…”

The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery

“…Moderate-topoor clopidogrel responders have a similar time recovery of platelet function compared with ticagrelor-treated patients after cessation of the treatment. In contrast, about one third of patients with ongoing clopidogrel intake have a high level of platelet inhibition, thus explaining why these patients may be particularly vulnerable to bleeding complications, especially if its administration is not interrupted at least 5 days before surgery, as recommended by the current guidelines [15][16][17]. Precisely because of the variable anti-aggregation response that patients can present with the intake of clopidogrel, Mahla et al [18], in 180 elective CABG patients, showed that a strategy based on preoperative platelet function testing to determine the timing of CABG in clopidogrel-treated patients was associated with the same amount of bleeding observed in clopidogrel-naive patients, with about 50% shorter waiting time than that recommended by the current guidelines.…”

Optimal Anticoagulation during Off Pump Coronary Artery Bypass in Patients Recently Exposed to Clopidogrel

“…Although OPCAB has been safely performed in these patients,15-17 clopidogrel therapy in proximity to surgery carries a considerable risk of hemorrhagic complications 18,19. Thus, it is reasonable to assume that these patients may benefit from a lower target range of ACT without being exposed to an increased risk of ischemic complications; however, no comprehensive studies exist.…”