Key result
Prior clopidogrel exposure before coronary artery bypass grafting is associated with a two to three-fold increase in reexploration for excessive bleeding.
Why the study?
Does early CABG after clopidogrel exposure increase bleeding complications compared to discontinuing clopidogrel for 5-7 days?
Does early CABG after clopidogrel exposure increase bleeding complications compared to discontinuing clopidogrel for 5-7 days?
Effect estimate: two to three-fold increase
The decision to perform early CABG in patients on clopidogrel requires balancing a 2-3 fold increased risk of reexploration for bleeding against a 1% risk of coronary events if surgery is delayed.
May warrant delaying elective CABG after clopidogrel when feasible; leaves open optimal timing in urgent cases pending prospective trials.
PURPOSE OF REVIEW: Current guidelines for the management of acute coronary syndrome clearly recommend that clopidogrel should be started before diagnostic coronary angiography. If patients undergo coronary artery bypass grafting (CABG) early after clopidogrel loading or during continued exposure, it seems reasonable to expect an increase in bleeding complications. RECENT FINDINGS: Earlier studies may have overestimated the risk of bleeding in patient undergoing CABG with prior clopidogrel exposure (5-10-fold increase). Some conflicting results are reported in literature. As reexploration because of excessive bleeding is concerned, a two to three-fold increase must be expected, which is demonstrated in actual trials properly matched to confounding factors. Discontinuation of clopidogrel for 5-7 days prior to urgent CABG as recommended by guidelines is not well adopted in clinical practice for several reasons. SUMMARY: There is a moderately elevated risk of bleeding complications after CABG due to prior clopidogrel exposure alone. However, in clinical practice this risk is added often to patients who carry already elevated surgical risks (urgent procedures, worse coronary anatomy, history of previous myocardial infarction and prior percutaneous intervention), and after bleeding complications singular patients may suffer from consecutive adverse outcome. Cessation of clopidogrel in patients before CABG clearly prolongs hospitalization time and has an estimated 1% risk of coronary events during the waiting period. Risk and benefit have to be balanced in every individual case.
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Carrel et al. (2009) conducted a review in Acute coronary syndrome undergoing coronary artery bypass grafting. Clopidogrel exposure prior to CABG was evaluated on Reexploration because of excessive bleeding (two to three-fold increase). Prior clopidogrel exposure before coronary artery bypass grafting is associated with a two to three-fold increase in reexploration for excessive bleeding.
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