Key result
Preoperative clopidogrel plus aspirin in CABG increases bleeding re-operations ~150% and death without reducing MACE.
Why the study?
Does preoperative use of P2Y12 receptor inhibitors affect the risk of bleeding, mortality, and major adverse cardiac events in patients undergoing cardiac and non-cardiac surgery?
Meta-Analysis (n=50,048)
Does preoperative use of P2Y12 receptor inhibitors affect the risk of bleeding, mortality, and major adverse cardiac events in patients undergoing cardiac and non-cardiac surgery?
Effect estimate: RR 2.5 (95% CI 1.92-3.25)
p-value: p=<0.001
Preoperative exposure to clopidogrel on top of aspirin before surgery increases the risk of major bleeding and mortality without providing a reduction in major adverse cardiac events.
Avoid preoperative clopidogrel plus aspirin before CABG; reinforces guidelines favoring aspirin monotherapy.
OBJECTIVE: receptor inhibitors). Outcomes evaluated were re-operation for major bleeding, death, myocardial infarction, combined major adverse cardiac events (MACEs) and major haematoma. Using a random effect model, relative risks (RRs) and 95% confidence intervals (CI) were calculated for each outcome. RESULTS: Fifty-four studies met the selection criteria and included 50,048 patients. Preoperative use of clopidogrel on top of aspirin in patients undergoing coronary artery bypass graft was associated with a 2.5-fold increased risk of re-operation for bleeding (95% CI: 1.92-3.25; p<0.001) and a 1.47-fold increased risk of death (95% CI: 1.25-1.72; p<0.001), but did not diminish the risk for myocardial infarction (RR: 0.96; 95% CI: 0.75-1.25; p=0.18) or MACE (RR: 1.16; 95% CI: 0.90--1.50; p=0.30). In patients undergoing non-cardiac surgery, preoperative use of clopidogrel increased the RR of re-operation for major bleeding by 2.05-fold (95% CI: 1.13-3.73; p=0.002) but did not reduce the RR for MACE or death. Clopidogrel use during cardiac device implantation raised the RR for procedure-related haematoma by 3.0-fold (95% CI: 1.30--6.94; p=0.001). Whereas preoperative ticagrelor use did not increase the risk for mortality (RR: 1.03; 95% CI: 0.49-2.14), preoperative prasugrel use tended to increase the risk for death (RR: 5.06; 95% CI: 0.54-47.65). CONCLUSION: Preoperative exposure to clopidogrel on top of aspirin did not reduce the risk of MACE but was associated with increased risk of bleeding and mortality.
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Siller‐Matula et al. (2015) conducted a meta-analysis in Cardiac and non-cardiac surgery (n=50,048). Preoperative P2Y12 receptor inhibitors (clopidogrel, ticagrelor, prasugrel) vs. Aspirin alone or no P2Y12 inhibitor was evaluated on Re-operation for major bleeding in patients undergoing coronary artery bypass graft (RR 2.5, 95% CI 1.92-3.25, p=<0.001). Preoperative use of clopidogrel on top of aspirin in CABG patients increased the risk of re-operation for bleeding (RR 2.5; 95% CI 1.92-3.25) and death, without reducing MACE.
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