Published online before print March 27, 2006, doi: 10.1161/CIRCULATIONAHA.105.571828
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(Circulation. 2006;113:1667-1674.)
© 2006 American Heart Association, Inc.
Cardiovascular Surgery |
Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery
Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?
From the Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center (E.I.K., D.A.M., K.R.P., P.C.H., M.K.C.D., A.S.B., S.W.B., P.J.C.), and Department of Epidemiology and Statistics, MedStar Research Institute (E.H.), Washington, DC.
Correspondence to Emmanouil I. Kapetanakis, MD, Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 110 Irving St NW, Room 1F-1207, Washington, DC 20010–2975 (e-mail emmanouil.kapetanakis{at}medstar.net); reprint requests to Paul J. Corso, MD, Chief, Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 106 Irving St NW, Suite 316, Washington, DC 20010–2975 (e-mail paul.j.corso@medstar.net).
Received June 27, 2005; revision received December 13, 2005; accepted January 20, 2006.
Background— Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach.
Methods and Results— Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different.
Conclusions— Clopidogrel administration in the cardiology suite increases the risk for hemostatic reoperation and the requirements for blood product transfusions during and after off-pump coronary artery bypass graft surgery.
CLINICAL PERSPECTIVE
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