European Heart Journal Advance Access originally published online on February 21, 2005
European Heart Journal 2005 26(6):576-583; doi:10.1093/eurheartj/ehi074
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Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?
1Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 106 Irving Street, NW, Suite 316, Washington, DC 20010-2975, USA
2Department of Epidemiology and Statistics, MedStar Research Institute, Washington, DC, USA
Received 3 May 2004; revised 28 September 2004; accepted 16 November 2004; online publish-ahead-of-print 21 February 2005.
* Corresponding author. Tel: +1 202 877 0277; fax: +1 202 291 1444. E-mail address: emmanouil_kapetanakis{at}yahoo.com
Aims Thrombotic complications after percutaneous coronary intervention procedures have decreased in past years mainly due to the use of clopidogrel antiplatelet therapy. However, the risk of bleeding due to enhanced and irreversible platelet inhibition in patients who will require surgical coronary revascularization instead has not been adequately addressed in the literature. The purpose of this study was to evaluate the effect of pre-operative clopidrogel exposure in haemorrhage-related re-exploration rates, peri-operative transfusion requirements, morbidity, and mortality in patients undergoing coronary artery bypass grafting (CABG) surgery.
Methods and results A study population of 2359 patients undergoing isolated CABG between January 2000 and June 2002 was reviewed. Of these, 415 (17.6%) received clopidogrel prior to CABG surgery, and 1944 (82.4%) did not. A risk-adjusted logistic regression analysis was used to assess the association between clopidogrel pre-medication (vs. no) and haemostatic re-operation, intraoperative and post-operative blood transfusion rates, and multiple transfusions received. Haemorrhage-related pre-operative risk factors identified from the literature and those found significant in a univariate model were used. Furthermore, a sub-cohort, matched-pair by propensity scores analysis, was also conducted. The clopidogrel group had a higher likelihood of haemostatic re-operation [OR=4.9, (95% CI, 2.63–8.97), P<0.01], an increase in total packed red blood cell transfusions [OR=2.2, (95% CI, 1.70–2.84), P<0.01], multiple unit blood transfusions [OR=1.9, (95% CI, 1.33–2.75), P<0.01] and platelet transfusions [OR=2.6, (95% CI, 1.95–3.56), P<0.01]. Surgical outcomes and operative mortality [OR=1.5, (95% CI, 0.36–6.51), P=0.56] were not significantly different.
Conclusion Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.
Key Words: Clopidogrel • Coronary artery bypass graft surgery • Re-operation due to bleeding • Transfusion rates • Haemostasis
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