European Heart Journal Advance Access published online on April 12, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm049
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Impact of aspirin with or without clopidogrel on postoperative bleeding and blood transfusion in coronary surgical patients treated prophylactically with a low-dose of aprotinin
1 Department of Anaesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, 47 Boulevard de l'Hôpital, Université Pierre et Marie Curie-Paris 6, 75651 Paris Cedex 13, France
2 EFS, Pitié-Salpêtrière University Hospital, Paris, France
3 Department of Thoracic and Cardiovascular Surgery, Institute of Cardiology, Pitié-Salpêtrière University Hospital, Paris, France
4 Department of Cardiology, Institute of Cardiology, Pitié-Salpêtrière University Hospital, Paris, France
5 Department of Emergency Medicine and Surgery, Pitié-Salpêtrière University Hospital, Paris, France
Received 6 May 2006; revised 1 February 2007; accepted 1 March 2007.
* Corresponding author. Tel: +33 1 42 16 22 51; fax: +33 1 42 16 22 69. E-mail address: alexandre.ouattara{at}psl.aphp.fr
Aims: Aspirin combined with clopidogrel is the treatment of choice for acute coronary syndromes. Although the maintenance of aspirin until surgery does not affect postoperative bleeding after coronary artery bypass graft (CABG) surgery, the latter may be dramatically increased when clopidogrel is continued over a period of 5 days preoperatively.
Methods and results: This prospective observational study included 217 consecutive patients scheduled for first-time CABG. Postoperative bleeding and blood transfusion requirements were compared (equivalence) between patients pretreated during a period of 5 days prior surgery by either aspirin alone (n = 157) or combined with clopidogrel (n = 60). Aprotinin was systematically used in all these patients considered as high risk for bleeding. We found no significant difference between both groups concerning the preoperative characteristics except for unstable angina (33 vs. 19%, P = 0.02) and left main coronary artery stenosis (27 vs. 13% P = 0.02), which were more frequent in patients receiving clopidogrel. The median chest tube output was similar in both groups 24 h postoperatively at 350 mL (95% CI 150–850) vs. 375 mL (95% CI 175–875), and the difference between groups (7%, 95% CI –9 to 22) did not encompass the predetermined margins of equivalence (25%). No significant difference was found on blood transfusion use (38 vs. 38%, P = 0.99). After adjustment by a propensity score, we found that clopidogrel was not associated with an increased risk of excessive bleeding.
Conclusion: In patients undergoing first-time CABG and treated prophylactically with aprotinin, aspirin and clopidogrel may be continued until surgery without increasing postoperative bleeding or transfusion requirements.
Key Words: Antifibrinolytic drug • Transfusion • Clopidogrel • Hemorrhage • Coronary surgery
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