Preoperative Clopidogrel Use Research Articles

Effect of anti-platelet therapy on peri-operative blood loss in patients undergoing off-pump coronary artery bypass grafting.

Purpose:The purpose of this study was to review the effect of the pre-operative use of clopidogrel and aspirin on peri-operative bleeding, blood product transfusion, and resource utilization after coronary artery bypass grafting (CABG).Materials and Methods:A total of 1200 patients who underwent off-pump CABG (OPCABG) between 2010 and 2012 were retrospectively studied. Patients were divided into three groups: group 1: discontinued aspirin and clopidogrel 6 days prior to surgery (n = 468), group 2: discontinued both drugs 3 to 5 days prior to surgery (n = 621), and group 3: discontinued both drugs 2 days prior to surgery (n = 111). The bleeding pattern and blood product transfusion were studied and compared between the groups. Patients having history of other drugs affecting the coagulation profile, other organ dysfunction, on-pump CABG, and the combined procedure were excluded from the study.Results:Group 2 patients had a higher rate of bleeding and a reduced mean value of hemoglobin (Hb) as compared to other groups. The same results were seen in blood and blood product transfusion. Patients of group 2 and group 3 were associated with higher blood loss in terms of drainage at 12 and 24 hours. Post-operatively, this was statistically significant. Re-exploration was statisitically significant in group 3 patients (9.01%) than in group 2 (2.58%) and group 1 (1.07%) patients.Conclusion:The pre-operative use of clopidogrel and aspirin in patients undergoing OPCABG showed limited clinical benefits; however, its use significantly increased the risk of bleeding and blood transfusion, thus increasing morbidity and resource utilization. Hence, clopidogrel and aspirin should be stopped at least 6 days prior to surgery.

Post Operative Complications Associated with Preoperative use of Clopidogrel in Patients Undergoning Coronary Artery Bypass Surgery

Background: Majority of the patients presenting for coronary artery bypass surgery are preoperatively on clopidogrel and aspirin i.e., Dual antiplatelets therapy (DAPT) because of high incidence of left main stem disease, acute coronary syndrome and diffuse coronary artery disease. Preceding coronary stenting and coming from far flung areas even from other countries with poor socioeconomic status contributes to continuation of DAPT till surgery. The main objective of the study was to evaluate hospital complications like chest tube output, re-explorations, blood, and blood product administration and in-hospital mortality in patients who continued DAPT till 48 hours prior to surgery versus those who continued DAPT until 48 to 120 hours before surgery. Methods: Preoperative history, perioperative and postoperative data of patients was gathered retrospectively from 1st July to 31st December 2019 in a tertiary care hospital of Peshawar. Total patients undergoing CABG Surgery were 223. From those 223 patients 192 patients were on DAPT. We than divided the 192 patients into two groups, Group A and Group B. 102 patients (Group A) received clopidogrel plus aspirin until 48 hours before surgery, and 89 patients (Group B) continued clopidogrel 48 to 120 hours prior to surgery. Chest tube output, need for exploration, in-hospital mortality, and blood or products transfusions among both groups were compared. Results: In terms of bleeding complications no significant difference between the both groups with similar chest drainage in the first 24 hours (602 ml and 609ml). In group A 33 patients received blood transfusion compared to 25 patients from group B. There was no significant difference in the amount of platelets given to group A (0.63 L) and to group B was (0.60 L). On the other hand, Group, A received 1.08 L fresh frozen plasma (FFPs) transfusion and group B 1.10 L respectively. Re-exploration was observed in Group A and B as (3 vs 2). Mortality was observed in 7 patients from group A and 2 from Group B. Conclusions: Usage of Dual antiplatelets therapy (DAPT) before surgery was an effective treatment method for postoperative complication of bleeding. It was suggested that with proper management with DAPT before surgery was planned is an effective and safe treatment method.. Keywords: Cardiopulmonary surgery, Coronary bypass grafting, hemoglobin, platelets, bleeding.

Preoperative clopidogrel and outcomes in patients with acute coronary syndrome undergoing coronary artery bypass surgery

ObjectiveThe optimal preoperative antiplatelet strategy for patients with acute coronary syndrome (ACS) requiring surgical revascularization remains unclear because of competing risks of bleeding and ischemic events. We evaluated the effect of clopidogrel within 5 days before coronary artery bypass grafting (CABG) on outcomes in patients with ACS. MethodsConsecutive patients with ACS who underwent isolated CABG at a single center were included in this retrospective study. The primary outcome was a composite of death, myocardial infarction, and stroke within 30 days after surgery. Secondary outcomes were CABG-related major bleeding and perioperative transfusion. Inverse probability weighting using propensity score was performed to evaluate the risk-adjusted effect of preoperative clopidogrel on outcomes. ResultsOf 5543 patients with ACS, 820 (14.8%) patients continued clopidogrel within 5 days before CABG. After adjustment for differences in baseline factors, clopidogrel use ≤5 days before CABG was associated with significantly increased odds of the primary composite outcome (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.29; P = .005), stroke (OR, 3.13; 95% CI, 1.82-5.39; P < .001), major bleeding (OR, 2.01; 95% CI, 1.56-2.58; P < .001), and transfusion (OR, 2.05; 95% CI, 1.82-2.30; P < .001). The effects of preoperative clopidogrel use ≤5 days on primary outcome and major bleeding were greater in patients older than 65 years. ConclusionsAmong patients with ACS undergoing CABG, clopidogrel therapy within 5 days before surgery was associated with increased odds of major cardiac and cerebrovascular events and bleeding complications than discontinuing clopidogrel for >5 days.

The impact of foot infection on infrainguinal bypass outcomes in patients with chronic limb-threatening ischemia

BackgroundDespite advances in endovascular therapy, infrainguinal bypass continues to play a major role in achieving limb salvage. In this study, we sought to compare outcomes of infrainguinal bypass in patients with limb-threatening ischemia who presented with or without foot infection. MethodsWe conducted a retrospective cohort study of patients who underwent infrainguinal bypass for chronic limb-threatening ischemia at a single institution. End points of interest included long-term mortality, 45-day readmission, postoperative length of stay (LOS), major amputation, and time to wound healing. Multivariable Cox, logistic, and robust regressions were used to model time to event outcomes, readmission rates, and LOS. ResultsThere were 454 infrainguinal bypass procedures analyzed. Demographics and baseline characteristics were similar, except congestive heart failure and diabetes were more common in the infection group. Presence of foot infection had no impact on mortality (hazard ratio [HR], 0.78; P = .243). Significant predictors of long-term mortality included increasing age, hypoalbuminemia, and congestive heart failure; preoperative use of clopidogrel was protective. Presence of foot infection was an independent predictor of major amputation. In the multiple regression model, the presence of foot infection was independently associated with amputation rate (HR, 2.14; 95% confidence interval, 1.42-3.22; P < .001); use of venous conduit and increasing age and body mass index were protective. Foot infection was an independent predictor of prolonged LOS (mean LOS was 1.54 days longer in patients with vs those without infection; P = .001). Other independent predictors of prolonged LOS included intraoperative blood loss and reoperation; history of continuous preoperative aspirin use and normal baseline renal function and albumin levels were associated with decreased LOS. Readmission was influenced by reoperation (odds ratio [OR], 2.51; P < .001) but not by presence of foot infection (OR, 1.21; P = .349). There was a strong trend for prolonged wound healing time in patients with diabetes (HR, 1.58; P = .05) but not in those with foot infection (OR, 0.74; P = .36). ConclusionsAmong patients requiring infrainguinal bypass for limb-threatening ischemia, infection was more common in patients with diabetes and was a significant predictor of major amputation and prolonged LOS. Infection was not predictive of mortality, wound healing time, or readmission. These findings lend support to the inclusion of infection in risk stratification schemes for patients with chronic limb-threatening ischemia, as recommended in the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system, because of its adverse impacts on limb salvage.

Preoperative Use of Clopidogrel Does Not Affect Outcomes for Femoral Neck Fractures Treated With Hemiarthroplasty

BackgroundThe antiplatelet effect of clopidogrel on blood loss and perioperative complications after surgical intervention remains ambiguous. The purpose of this study was to determine if patients on clopidogrel before hemiarthroplasty for femoral neck fracture are predisposed to greater surgical bleeding and perioperative complications compared with those not taking clopidogrel before surgery. MethodsWe conducted a review of our electronic medical record from 2006-2013 and identified 602 patients who underwent 623 hemiarthroplasty procedures for displaced femoral neck fracture, of which 54 cases (9%) were taking clopidogrel before hospital admission. Patient demographics and comorbidities, operative and surgical variables, and perioperative complications at 90 days were compared between the clopidogrel and nonclopidogrel user groups. ResultsThe 2 groups of patients had similar baseline characteristics, but patients taking clopidogrel preoperatively were sicker with higher American Society of Anesthesiologists scores (P = .049) and age-adjusted Charlson index (P = .001). They also had a greater incidence of cerebrovascular disease (P = .01), chronic obstructive pulmonary disease (P = .03), diabetes (0.03), and malignancy (P < .001). There was no significant difference between the 2 patient groups with respect to 90-day postoperative medical readmissions (P = .85), surgical readmissions (P = .26), infection (P = .99), and mortality (P = .89). ConclusionPatients taking clopidogrel who present with a displaced femoral neck fracture can safely undergo a hemiarthroplasty while actively on clopidogrel without an increase in medical or surgical complications and mortality. We do not recommend delaying surgical intervention until the antiplatelet effects of clopidogrel subside.

Preoperative antiplatelet use does not increase incidence of bleeding after major operations

This study examined the outcomes of patients holding or continuing clopidogrel during the preoperative period. We reviewed all patients taking clopidogrel who underwent one of 72 different Current Procedural Terminology code procedures, representing major emergency and elective general thoracic and vascular operations from 2009-2012 at a single institution. Demographics, comorbidities, aspirin use, details of coronary stents, and perioperative events were collected. A total of 2,154 major operative procedures were performed on 1,851 patients during the study period. A total of 213 patients (11.5%) were taking clopidogrel at the time of their last office visit or hospital admission and were then instructed to hold or continue the drug prior to an operation. A total of 205 procedures in 200 patients comprised the final study population. Clopidogrel was held in 116 procedures for ≥5days prior to operative intervention (56.6%, Group A), and clopidogrel was administered within 5days of an operation in 89 procedures (43.4%, Group B). There were no differences between the 2 groups regarding estimated blood loss, units transfused, myocardial infarction, stroke, acute visceral or peripheral ischemia, or death within 30days. We did not identify significantly increased adverse patient outcomes in those patients who received preoperative clopidogrel within this population. We assert that it appears to be reasonable and safe to continue antiplatelet therapy with clopidogrel in this population in elective situations and that preoperative clopidogrel use does not increase the risk of bleeding in emergency circumstances.

Impact of Foot Infection on Infrainguinal Bypass Outcomes in Patients With Limb-Threatening Ischemia

Despite advances in endovascular therapy, infrainguinal bypass (IB) continues to play a major role in achieving limb salvage in the patients with extensive tissue loss and long-segment occlusive disease. In this study, we sought to compare the outcomes of IB in patients with limb-threatening ischemia who presented with or without foot infection. We conducted a retrospective cohort study of patients who underwent IB for limb-threatening ischemia at a single institution. Patient-related end points of interest included long-term mortality, 6-month readmission, and postoperative length of stay (LOS). Limb-related end points included major amputation (transfemoral, transtibial, or through the knee) and time to wound healing. Multivariable Cox, logistic, and robust regression were used to model time-to-event outcomes, readmission rates, and LOS respectively. Overall, 454 IB procedures that occurred over a 7-year period were analyzed. Demographics and baseline patient characteristics were similar between the infection and noninfection group, except congestive heart failure and diabetes were more common in the infection group. Presence of foot infection had no impact on mortality (HR, 0.72; P = .113). Statistically significant predictors of long-term mortality included increasing age, hypoalbuminemia, and congestive heart failure, whereas preoperative use of clopidogrel was protective (Table I). The presence of foot infection was an independent predictor of major ipsilateral amputation (HR, 1.86; P = .002). Other significant predictors of major amputation on multivariable analysis included history of statin administration, decreasing age, and low body mass index (Table I). In addition, foot infection was an independent predictor of prolonged LOS (mean LOS was 1.7 days longer in patients with vs those without infection; P < .001). Other independent predictors of prolonged LOS included intraoperative blood loss and reoperation in the index extremity; whereas, history of continuous preoperative aspirin use, normal renal function, and normal albumin levels were associated with decreased LOS (Table II). Readmission was influenced by the performance of a reoperation in the index extremity (OR, 2.57; P < .001) and history of diabetes (OR, 1.5; P = .023) but not the presence of foot infection (OR, 1.27; P = .192) There was a strong trend for prolonged wound healing time in patients with diabetes (HR, 1.57; P = .05), but not in those with foot infection (OR, 0.73; P = .36). Among patients requiring infrainguinal bypass for limb-threatening ischemia, infection was more common in patients with diabetes and was a significant predictor of major amputation and prolonged LOS. Infection was not predictive of mortality, wound healing time, or readmission. These findings lend additional support to the inclusion of infection in risk-stratification schemes for patients with limb-threatening ischemia, as recommended in the Society for Vascular Surgery WIfI Classification System, because of its adverse impacts on limb salvage.Table ISignificant predictors of mortality and major amputation among those undergoing infrainguinal bypassVariableHazard ratio95% Confidence intervalP valueMortality Age1.041.02-1.07<.001 Congestive heart failure2.061.26-3.36.004 Albumin0.610.45-0.82.001 Clopidogrel0.430.25-0.74.003Major amputation Infection1.861.25-2.78.002 Age0.960.93-0.99.025 Body mass index0.940.91-0.98.014 Statin1.921.14-3.24.014 Open table in a new tab Table IISignificant predictors of postoperative length of stay (LOS) among those undergoing infrainguinal bypass (IB)VariableCoefficient95% Confidence intervalP valueInfection1.660.76-2.55<.001Glomerular filtration rate−0.02−0.043 to −0.014<.001Aspirin−1.16−2.13 to −0.18.02Albumin−1.35−2.11 to −0.60<.001Redo-open1.360.49-2.24.02Operating room estimated blood loss0.0030.001-0.004<.001 Open table in a new tab

Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis

To review systematically the evidence and perform a meta-analysis of benefits and risks associated with use of P2Y12 receptor inhibitors in coronary artery bypass graft-, non-cardiac- and device surgery. Data selection and analysis: We performed a meta-analysis of published studies. Patients with preoperative use of clopidogrel, ticagrelor or prasugrel (late discontinuation: <5 days before surgery or no discontinuation) were compared with patients without preoperative use of the respective drug (early discontinuation: ⩾5 days before surgery or no users of P2Y12 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. 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). 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.

Does incorporation of thromboelastography improve bleeding prediction following adult cardiac surgery?

Cardiopulmonary bypass (CPB) coagulopathy increases utilization of allogenic blood/blood products, which can negatively affect patient outcomes. Thromboelastography (TEG) is a point-of-care measurement of clot formation and fibrinolysis. We investigated whether the addition of TEG parameters to a clinically based bleeding model would improve the predictability of postoperative bleeding. A total of 439 patients’ charts were retrospectively investigated for 8-h chest tube output (CTO) postoperatively. For model 1, the variables recorded were patient age, gender, body surface area, clopidogrel use, CPB time, first post-CPB fibrinogen serum level, first post-CPB platelet count, first post-CPB international normalized ratio, the total amount of intraoperative cell saver blood transfused, and postoperative first ICU hematocrit level. Model 2 had the model 1 variables, TEG angle, and maximum amplitude. The outcome was defined as 0–8-h CTO. The predictor variables were placed into a forward stepwise regression model for continuous outcomes. Analysis of variance with adjusted R2 was used to assess the goodness-of-fit of both predictive models. The predictive accuracy of the model was examined using CTO as a dichotomous variable (75th percentile, 480 ml) and receiver operating characteristic curves for both models. Advanced age, male gender, preoperative clopidogrel use for 5 days or less, greater cell saver blood utilization, and lower postoperative hematocrit levels were associated with increased 8-h CTO (P < 0.05). Adding TEG angle and maximum amplitude to model 1 did not improve CTO predictability. When TEG angle and maximum amplitude were added as predictor factors, the predictability of the bleeding model did not improve.

Effect of Clopidogrel Use Post Coronary Artery Bypass Surgery on Graft Patency

Clopidogrel use post coronary artery bypass grafting (CABG) has become more popular under the assumption that it improves graft patency. The purpose of this sub-analysis from the Randomized On and Off-Pump Bypass (ROOBY) trial is to evaluate the role of clopidogrel use post CABG to improve graft patency when added to standard aspirin therapy. The ROOBY trial was a multi-center, randomized, controlled clinical trial that compared on-pump versus off-pump coronary artery bypass grafting (CABG). Clopidogrel use post CABG was left at the discretion of the operator. Detailed data regarding the use and timing of clopidogrel post CABG were collected prospectively, along with 1-year angiograms to evaluate graft status. Of the 2,203 subjects undergoing CABG, 953 patient records had complete clopidogrel use and 1-year angiographic data. Of these, 345 (36.2%) received clopidogrel post CABG prior to discharge. Compared with patients with no post-CABG clopidogrel use, baseline characteristics were similar for the clopidogrel group except for the following: lower preoperative aspirin use (80.2% vs 86.7%, p = 0.009); higher preoperative clopidogrel use (23.5% vs 14.0%, p < 0.001), less on-pump (35.9% vs 55.9%, p < 0.0001); and lower endoscopic vein harvesting (30.8% vs 42.5%, p < 0.001) rates. Overall 1-year graft patency rates were not different between the clopidogrel and no-clopidogrel groups (86.5% vs 85.3%, p = 0.43). Multivariable analyses did not alter these findings. This study suggests that routine post-CABG clopidogrel use may not translate to improved 1-year graft patency. Future studies appear warranted to better define the role of more aggressive antiplatelet therapy post CABG on graft patency and clinical outcomes.

Antiplatelet therapy at the time of coronary artery bypass grafting: a multicentre cohort study

The purpose of this multicentre cohort study was to examine the relationship between antiplatelet therapy (APT) at the time of coronary artery bypass grafting (CABG) and postoperative bleeding complications, transfusion requirements and adverse cardiovascular events. A matched-pair analysis was carried out on 6350 consecutive patients undergoing CABG at the three university hospitals in Western Denmark. Patients exposed to aspirin or clopidogrel within 5 days before surgery were compared with those not exposed to these drugs. The data used in the study were retrieved from the Western Denmark Heart Registry. Of the 6350 patients enrolled, 1846 (29%) had been exposed to aspirin or clopidogrel within 5 days prior to CABG (the APT group). Matching with the remaining 4504 (71%) patients of the control group resulted in 1132 pairs of patients. Patients in the APT group had greater mean chest tube drainage volumes (946 vs 775 ml; P < 0001) and greater transfusion requirements (ranging from 37.4-57.5 vs 29.8%; P < 0.0001) than control group patients. Preoperative aspirin therapy was not associated with greater reoperation rates (4.0 vs 3.9%; P = 0.005); nor was it an independent risk factor for severe postoperative bleeding >1000 ml (odds ratio [OR]: 1.07, 95% confidence interval [CI]: 0.55-1.34). Preoperative clopidogrel use, on the other hand, was associated with greater reoperation rates (10.2 vs 3.9% in the control group; P = 0.005) and was an independent predictor of severe postoperative bleeding (OR: 2.08, 95% CI: 1.55-2.80). Overall, preoperative APT had no significant effect on postoperative 30-day mortality, incidence of myocardial infarction, stroke or need for dialysis. Preoperative APT is associated with increased bleeding and greater transfusion requirements after CABG. Clopidogrel exposure is associated with greater reoperation rates and is an independent risk factor for severe postoperative bleeding.

Bleeding-associated outcomes with preoperative clopidogrel use in on- and off-pump coronary artery bypass

Clopidogrel use prior to coronary artery bypass graft surgery in patients presenting with acute coronary syndromes is associated with a greater incidence of procedural related morbidity. We studied the impact of clopidogrel pre-treatment in patients undergoing off-pump versus on-pump coronary revascularization. This report describes a post hoc analysis of 431 on-pump and 165 off-pump cases from a retrospective multicenter study of the impact of preoperative (within 5 days) clopidogrel use on bleeding related outcomes and surgical reintervention. Logistic regression was used to analyze the outcomes with respect to surgery type and clopidogrel exposure while using a propensity score risk adjustment for off-pump surgery. The hospital length of stay (9.3 ± 5.4 days vs. 8.9 ± 5.3 days, p = 0.35), major bleeding (21% vs. 20%, p = 0.74) and reoperation (3.7% vs. 4.8%, p = 0.53) were similar between on-pump and off-pump, respectively. In both surgical cohorts, recent clopidogrel use was associated with a greater incidence of major bleeding, reoperation, and transfusion. After multivariable adjustment, the odds ratio of major bleeding (1.76, 95% confidence interval 0.88-3.52 on-pump; 2.37, 95% confidence interval 1.06-5.30 off-pump) and reoperation (4.52, 95% confidence interval 0.58-36.6 in on-pump; 7.05, 95% confidence interval 0.82-60.5 in off-pump) was increased in clopidogrel-treated patients compared to no clopidogrel. Major bleeding and reoperation did not differ significantly between patients undergoing on- or off-pump surgery. Clopidogrel treatment within 5 days prior to surgery increased the risk of bleeding and reoperation in all CABG patients irrespective of whether surgery was performed on- or off-pump.

Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery

Persistent variation in practice surrounds preoperative clopidogrel management at the time of vascular surgery. While some surgeons preferentially discontinue clopidogrel citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel for an appropriate indication. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery. We reviewed a prospective regional vascular surgery registry recorded by 66 surgeons from 15 centers in New England from 2003 to 2009. Preoperative clopidogrel use within 48 hours of surgery was analyzed among patients undergoing carotid endarterectomy (CEA), lower extremity bypass (LEB), endovascular abdominal aortic aneurysm repair (EVAR), and open abdominal aortic aneurysm repair (oAAA). Ruptured AAAs were excluded. Endpoints included postoperative bleeding requiring reoperation, as well as the incidence and volume of blood transfusion. Statistical analysis was performed using analysis of variance, Fisher exact, χ(2), and Wilcoxon rank-sum tests. Over the study interval, a total of 10,406 patients underwent surgery, including 5264 CEA, 2883 LEB, 1125 EVAR, and 1134 oAAA repair. Antiplatelet use among all patients varied, with 19% (n = 2010) taking no antiplatelet agents, 69% (n = 7132) taking aspirin (ASA) alone, 2.2% (n = 229) taking clopidogrel alone, and 9.7% (n = 1017) taking both ASA and clopidogrel. Clopidogrel alone or as dual antiplatelet therapy was most frequently used prior to CEA and least frequently prior to oAAA group (CEA 16.1%, LEB 9.0%, EVAR 6.5%, oAAA 5%). Reoperation for bleeding was not significantly different among patients based on antiplatelet regimen (none 1.5%, ASA 1.3%, clopidogrel 0.9%, ASA/clopidogrel 1.5%, P = .74). When analyzed by operation type, no difference in reoperation for bleeding was seen across antiplatelet regimens. There was also no difference in the incidence of transfusion among antiplatelet treatment groups (none 18%, ASA 17%, clopidogrel 0%, ASA/clopidogrel 24%, P = .1) and none when analyzed by individual operation type. Among patients who did require transfusion, there was no significant difference in the mean number of units of packed red blood cells required (none 0.7 units, ASA 0.5 units, clopidogrel 0 units, ASA/clopidogrel 0.6 units, P = .1) or when stratified by operation type. Patients undergoing peripheral arterial surgery in whom clopidogrel was continued either alone or as part of dual antiplatelet therapy did not have significant bleeding complications compared with patients taking no antiplatelet therapy or ASA alone at the time of surgery. These data suggest that clopidogrel can safely be continued preoperatively in patients with appropriate indications for its use, such as symptomatic carotid disease or recent drug-eluting coronary stents.

Clopidogrel Is Not Associated With Major Bleeding Complications During Peripheral Arterial Surgery

Persistent variation in practice surrounds preoperative clopidogrel (Plavix) management at the time of vascular surgery. Although some surgeons preferentially discontinue clopidogrel, citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery. We reviewed a prospective regional vascular surgery registry (VSGNE) of 66 surgeons from 12 centers in New England from 2003-2009. Preoperative clopidogrel use ≤48 hours of surgery was analyzed among patients undergoing carotid endarterectomy (CEA), lower extremity bypass (LEB), endovascular abdominal aortic aneurysm repair (EVAR), and open abdominal aortic aneurysm (AAA) repair. End points included postoperative bleeding requiring reoperation as well as blood transfusion. Statistical analysis was performed using Fisher exact and Wilcoxon rank sum tests. During the study interval, 5264 patients underwent CEA, 2883 underwent LEB, 1153 underwent EVAR, and 1330 underwent open AAA repair, in whom 16.2%, 9.0%, 6.9%, and 4.6% were maintained on clopidogrel, respectively. Reoperation for bleeding was not significantly different among patients taking clopidogrel vs patients not taking clopidogrel at the time of surgery across all operation categories. There was no difference in the incidence of transfusion among treatment groups for all types of operation (Table). In addition, among patients who did require transfusion, there was no significant difference between clopidogrel-treated and non-clopidogrel-treated groups in the mean units of packed red blood cells required (Table).Tabled 1 Open table in a new tab Patients undergoing peripheral arterial surgery in whom clopidogrel was continued did not have significant bleeding complications compared with patients not on clopidogrel. These data provide reassurance that clopidogrel can safely be continued preoperatively in patients with important indications for its use, such as symptomatic carotid disease or recent drug-eluting cardiac stents.

Efficiency of Preoperative Tranexamic Acid in Coronary Bypass Surgery: An Analysis Correlated with Preoperative Clopidogrel Use

This study evaluates the efficiency of prophylactic tranexamic acid in coronary bypass surgery with respect to preoperative clopidogrel use. We analyzed data for 3754 consecutive patients who underwent isolated coronary bypass surgery with cardiopulmonary bypass between January 1999 and August 2008. The patients were placed into 4 groups according to the perioperative use of clopidogrel and tranexamic acid. Group 1 included patients administered neither of these medications (n = 3160, 84.2%); group 2 included patients who received tranexamic acid only (n = 444, 11.8%); group 3 included patients who received clopidogrel only (n = 113, 3.0%); and group 4 included patients who received both medications (n = 37, 1.0%). In patients who received tranexamic acid, we noted significant decreases in postoperative drainage (615 +/- 336 mL versus 458 +/- 289 mL, group 1 versus group 2 [P = .0001]; 740 +/- 399 mL versus 570 +/- 408 mL, group 3 versus group 4 [P = .03]) and the use of fresh frozen plasma (1.4 +/- 1.4 units/patient versus 0.2 +/- 0.7 units/patient, group 1 versus group 2 [P = .0001]; 2.2 +/- 1.7 units/patient versus 0.5 +/- 1.3 units/patient, group 3 versus group 4 [P = .0001]), irrespective of the use of clopidogrel. We found significant decreases in postoperative blood transfusion (0.59 +/- 1.1 units/patient versus 0.39 +/- 1.1 units/patient, group 1 versus group 2 [P = .0001]; 1.2 +/- 1.8 units/patient versus 0.7 +/- 1.1 units/patient, group 3 versus group 4 [P > .05]) and in the percentage of patients who received transfusions (31.3% versus 19.3%, group 1 versus group 2 [P = .0001]; 54.5% versus 37.8%, group 3 versus group 4 [P > .05]) only in the patients who did not receive clopidogrel. Prophylactic tranexamic acid reduces bleeding and the need for transfusion. This effect exists in patients using clopidogrel but is less prominent. Preoperative use may be beneficial in patients using clopidogrel without any need for delaying the surgical procedure.

Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting

Preoperative use of clopidogrel increases the risk of bleeding, but its postoperative use has not been studied. We studied early postoperative clopidogrel use in on-pump and off-pump coronary artery bypass grafting. Data were obtained from the University HealthSystem Consortium database. We conducted a retrospective analysis of data of 15,067 adults who had coronary artery bypass grafting between 2003 and 2006 and received perioperative aspirin alone or in combination with clopidogrel, with the latter administered within 2 days after coronary artery bypass grafting. Logistic regression was used to analyze in-hospital mortality, 30-day readmission, ischemic or thrombotic events, and bleeding events, with propensity score adjustment for clopidogrel treatment. Combined aspirin and clopidogrel were used in 3268 patients (22%). Compared with aspirin alone, aspirin plus clopidogrel was associated with reductions of in-hospital mortality (0.95% vs 1.78%; adjusted odds ratio: 0.50; 95% confidence interval: 0.25, 0.99) and bleeding events (4.19% vs 5.17%; adjusted odds ratio: 0.70; 95% confidence interval: 0.51, 0.97). Ischemic or thrombotic events were not significantly different (1.29% vs 1.53%; adjusted odds ratio, 0.99; 95% confidence interval: 0.59, 1.64). The relative effect of combined treatment did not differ between on-pump and off-pump coronary artery bypass grafting. Early postoperative clopidogrel combined with aspirin may be safe and beneficial compared with perioperative aspirin treatment alone, in both on-pump and off-pump coronary artery bypass grafting. However, a possibility of selection bias calls for randomized controlled trials to confirm our findings.

RR1. Pre-operative Use of Clopidogrel and Aspirin Versus Aspirin is Associated with a Stable Atherosclerotic Plaque Phenotype

RR1. Pre-operative Use of Clopidogrel and Aspirin Versus Aspirin is Associated with a Stable Atherosclerotic Plaque Phenotype

Noncardiac Surgery for Patients with Coronary Artery Stents

Physicians are increasingly being confronted with questions regarding the appropriate management of patients with recently implanted coronary stents who are in need of noncardiac surgery. Specifically, what is the optimal timing of elective procedures and how should antiplatelet therapy be managed in these patients, especially in those in need of emergent procedures? Continued antiplatelet therapy through the perioperative period might increase the risk of surgical bleeding while interruption of antiplatelet therapy predisposes to stent thrombosis, particularly in the setting of systemic hypercoagulation that frequently occurs after some surgeries.1 In this issue of Anesthesiology, two papers from the Mayo Clinic in Rochester, Minnesota provide further insight into these perplexing issues.2,3

Clopidogrel and Bleeding After Coronary Artery Bypass Graft Surgery

There is evidence that clopidogrel (with or without aspirin) confers superior outcomes in patients with coronary artery disease. The purpose of this study is to review the effect of preoperative clopidogrel administration on clinical outcome, bleeding complications and resource utilization after coronary artery bypass graft surgery. Patient data were prospectively collected from 919 patients who had isolated coronary surgery during the period 2000 to 2003. Outcome comparisons were studied, firstly between patients who received preoperative clopidogrel with those who did not, and secondly between patients on clopidogrel only, aspirin only, both or neither medications. Twenty-four patients (2.6%) were on clopidogrel only, 598 (65.1%) were on aspirin only, 61 (6.6%) were on both, and 236 (25.7%) were on neither. Clopidogrel (n = 85) versus no clopidogrel (n = 834): there were no significant differences in the off-pump patients. In the on-pump patients, the clopidogrel group had significantly increased bleeding (p = 0.02), blood transfused (p = 0.01), intensive care (p = 0.03), and hospital stays (p = 0.03). There were no significant differences in surgical reexploration, perioperative myocardial infarction, intraoperative balloon pump use, inotropic support or 30-day mortality. Clopidogrel versus aspirin versus both versus neither: patients on both clopidogrel and aspirin had significantly more postoperative bleeding than patients on aspirin alone or on neither medication. The preoperative use of clopidogrel in patients undergoing coronary artery bypass graft surgery showed limited clinical benefits; however, its use significantly increased the risk of bleeding, blood transfusion, and resource utilization.

The relationship between HbA1c & atrial fibrillation after off-pump coronary artery bypass surgery in diabetic patients.

Objective:Diabetes mellitus is recognized as a risk factor for mortality and morbidity after coronary bypass grafting. We aimed to determine the association between preoperative hemoglobin HbA1c and AF after isolated off-pump coronary bypass grafting (OPCAB).Methods:The seventy-two diabetic patients undergoing isolated off-pump coronary bypass grafting were retrospectively analyzed for AF. They were divided into; Low (4.8–5.4%), Medium (5.5–8%) and High (8.1–11.5%) groups. The three groups were compared with respect to demographic, echocardiographic, intraoperative and postoperative clinical characteristics correlation.Results:Three patients died during postoperative period. AF occurred in 12 patients (16.6%) after surgery. The incidence of postoperative AF was 15.3% in the lower, 4.4% middle and 57.1% upper group. There was statistically significant correlation between preoperative HbA1C and preoperative stroke, preoperative MI history, Left atrial (LA) size, preoperative levosimendan, preoperative clopidogrel, postoperative AF, postoperative dopamine and dobutamine use, IABP, duration of extubation time, 24-hour chest tube drainage, duration of ICU and hospital mortality. Univariate logistic regression analysis showed significant correlation between postoperative AF and variables like preoperative HbA1c levels, LVEF<30%, history of preoperative MI, preoperative use of levosimendan, preoperative use of clopidogrel, postoperative dopamine, dobutamine adrenaline use, left atrium size, 24-hour chest tube drainage and length of stay in the intensive care unit.Conclusion:Preoperative HbA1c levels could predict the occurrence of postoperative AF in diabetic patients and may entail to administer protective strategies.