Bleeding Outcomes Associated with Coronary Artery Bypass Graft Surgery and Recent Clopidogrel Exposure

  • Danielle M. Blais
  • Sarah M. Zukkoor
  • Charles Hayes
  • Kerry K. Pickworth
  • Kyle Porter
  • Michael S. Firstenberg

Abstract

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.

References

Angiolillo DJ, Fernandez-Ortiz A, Bernardo E, et al. 2007. Variability in individual responsiveness to clopidogrel: clinical implications, management, and future perspectives. J Am Coll Cardiol 49:1505-16.\nAngiolillo DJ, Firstenberg MS, Price MJ, et al, for the BRIDGE Investigators. 2012. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 307:265-74.\nBanbury MK, Brizzio ME, Rajeswaran J, Lytle BW, Blackstone EH. 2006. Transfusion increases the risk of postoperative infection after cardiovascular surgery. J Am Coll Surg 202:131-8.\nBiancari F, Airaksinen KE, Lip GY. 2011. Benefits and risks of using clopidogrel before coronary artery bypass surgery: systematic review and meta-analysis of randomized trials and observational studies. J Thorac Cardiovasc Surg 143:665-75.\nBurcham P, Blais D, Firstenberg MS. 2011. Platelet inhibition and surgical bleeding. A plea for more science and evidence-based guidelines. Circ J 75:2751-2.\nCAPRIE Steering Committee. 1996. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 348:1329-39.\nChen ZM, Jiang LX, Chen YP, et al. 2005. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 366:1607-21.\nDasarathan C, Vaidyanathan K, Chandrasekaran D, Cherian KM. 2011. Does preoperative clopidogrel increase bleeding after coronary bypass surgery? Asian Cardiovasc Thorac Ann 19:52-6.\nEbrahimi R, Dyke C, Mehran R, et al. 2009. Outcomes following preoperative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol 53:1965-72.\nFerraris VA, Brown JR, Despotis GJ, et al. 2011. 2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 91:944-82.\nFiranescu CE, Martens EJ, Schonberger JP, Soliman Hamad MA, van Straten AH. 2009. Postoperative blood loss in patients undergoing coronary artery bypass surgery after preoperative treatment with clopidogrel. A prospective randomised controlled study. Eur J Cardiothorac Surg 36:856-62.\nHerman CR, Buth KJ, Kent BA, Hirsch GM. 2010. Clopidogrel increases blood transfusion and hemorrhagic complications in patients undergoing cardiac surgery. Ann Thorac Surg 397-402.\nHongo RH, Ley J, Dick SE, Yee RR. 2002. The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting. J Am Coll Cardiol 40:231-7.\nKarabulut H, Toraman F, Evrenkaya S, Goksel O, Tarcan S, Alhan C. 2004. Clopidogrel does not increase bleeding and allogenic blood transfusion in coronary artery surgery. Eur J Cardiothorac Surg 25:419-23.\nLewis BS, Mehta SR, Fox KA, et al. 2005. Benefit of clopidogrel according to timing of percutaneous coronary intervention in patients with acute coronary syndromes: further results from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Am Heart J 150:1177-84.\nMaltais S, Perrault LP, Do QB. 2008. Effect of clopidogrel on bleeding and transfusions after off-pump coronary artery bypass graft surgery: impact of discontinuation prior to surgery. Eur J Cardiothorac Surg 34:127-31.\nMehran R, Pocock SJ, Stone GW, et al. 2009. Associations of major bleeding and myocardial infarction with the incidence and timing of mortality in patients presenting with non-ST-elevation acute coronary syndromes: a risk model from the ACUITY trial. Eur Heart J 30:1457-66.\nMehran R, Rao SV, Bhatt DL, et al. 2011. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 123:2736-47.\nMehta RH, Roe MT, Mulgund J, et al. 2006. Acute clopidogrel use and outcomes in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. J Am Coll Cardiol 48:281-6.\nNijjer SS, Watson G, Athanasiou T, Malik IS. 2011. Safety of clopidogrel being continued until the time of coronary artery bypass grafting in patients with acute coronary syndrome: a meta-analysis of 34 studies. Eur Heart J 32:2970-88.\nSabatine MS, Cannon CP, Gibson CM, et al. 2005. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 352:1179-89.\nWright RS, Anderson JL, Adams CD, et al. 2011. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. J Am Coll Cardiol 57:e215-367.\n
Published
2015-04-03
How to Cite
Blais, D., Zukkoor, S., Hayes, C., Pickworth, K., Porter, K., & Firstenberg, M. (2015). Bleeding Outcomes Associated with Coronary Artery Bypass Graft Surgery and Recent Clopidogrel Exposure. The Heart Surgery Forum, 16(2), E70-E77. https://doi.org/10.1532/HSF98.20121101
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Articles

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