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Safety of Continued Clopidogrel Use in the Preoperative Course of Gastrointestinal Surgery: A Retrospective Cohort Study. Ann Surg 2017; 265:370-378. [PMID: 27049768 DOI: 10.1097/sla.0000000000001726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our study aimed to estimate postoperative bleeding risk in older adults taking clopidogrel before gastrointestinal (GI) surgery, to aid surgeons in decisions regarding clopigogrel cessation. SUMMARY BACKGROUND DATA Balancing risks of postoperative bleeding associated with continued clopidogrel use and those associated with cessation is difficult for GI surgeons. METHODS Using 100% Texas Medicare Claims Data from 2006 to 2011, we identified patients undergoing emergent GI surgery. We propensity score matched patients on clopidogrel before surgery to patients not on clopidogrel. Using conditional logistic regression, we compared risks of bleeding events at 1-month postdischarge between groups, adjusting for bleeding risk factors. RESULTS In total, 1240 patients undergoing emergent GI surgery while treated with clopidogrel were matched to emergency GI surgery patients not treated with clopidogrel. The only significant preoperative differences between groups were higher percent of clopidogrel-treated patients with congestive heart failure, cholecystectomy, and lower percent of clopidogrel-treated patients with colectomy. Mean age was 76.91 (±7.06) and 76.70 (±7.05) years (P = 0.47), and 63.84% and 59.41% of operations were cholecystectomy, in the clopidogrel and nonclopidogrel groups (P = 0.18). In multivariable analyses adjusting for Elixhauser index, hyperlipidemia, confounding drugs, and surgery type, odds ratio for bleeding within 30 days of discharge in those exposed to clopidogrel compared with those not exposed was 1.60 (95% confidence interval, 1.08-2.38), with raw rates of bleeding 6.85% and 4.84%. CONCLUSIONS Clopidogrel use in older adults through the preoperative period of GI surgery does not significantly increase bleeding events in the month after surgery.
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Tibrewala A, Nassif ME, Andruska A, Shuster JE, Novak E, Vader JM, Ewald GA, LaRue SJ, Silvestry S, Itoh A. Use of adenosine diphosphate receptor inhibitor prior to left ventricular assist device implantation is not associated with increased bleeding. J Artif Organs 2016; 20:42-49. [PMID: 27830349 DOI: 10.1007/s10047-016-0932-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Current guidelines recommend adenosine diphosphate receptor inhibitors (ADPRi) be discontinued 5-7 days prior to cardiac surgery due to increased bleeding events, rates of re-exploration, and transfusions. However, the risks of left ventricular assist device (LVAD) implantation in patients taking an ADPRi have not previously been studied. We retrospectively identified 134 eligible patients with ischemic cardiomyopathy that underwent LVAD implantation between July 2009 and August 2013. The cohorts received an ADPRi ≤5 days of surgery (n = 25) versus >5 days prior or not at all (n = 109). Subgroup analyses adjusted for differences in frequency of redo sternotomy between cohorts, excluded patients that received an ADPRi >1 year prior to surgery, and excluded patients with a redo sternotomy. The ADPRi and control groups did not have significant differences in the primary outcomes, intraoperative PRBC units transfused (3.0 vs. 4.0, p = 0.12) or chest tube output within 24 h of surgery (1.66 L vs. 1.80 L, p = 0.61). After adjusting for differences in frequency of redo sternotomy (ADPRi vs. control, 12 vs. 52%, p ≤ 0.001), no significant difference in PRBC units transfused (3.1 vs. 3.5, p = 0.59) or chest tube output (2.04 L vs. 2.04 L, p = 0.98) was seen. No significant difference in 30-day mortality (8.0 vs. 11.0%, p = 0.63), 90-day mortality (16.4 vs. 23.3%, p = 0.42), or length of stay (29.0 vs. 28.0, p = 0.61) was seen. In this single-center experience, use of an ADPRi ≤5 days prior to LVAD implantation was not associated with increased bleeding, length of stay, or mortality.
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Affiliation(s)
- Anjan Tibrewala
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael E Nassif
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Adam Andruska
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerrica E Shuster
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric Novak
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin M Vader
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Ewald
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Shane J LaRue
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Scott Silvestry
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Campus Box 8234, 660 S Euclid Avenue, St. Louis, MO, 63110, USA
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Campus Box 8234, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.
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Gielen CLI, Bruggemans EF, Stijnen T, Eikenboom J, Tavilla G, Brand A, Klautz RJM. Stopping antiplatelet medication before coronary artery bypass graft surgery: is there an optimal timing to minimize bleeding? Eur J Cardiothorac Surg 2015; 48:e64-70. [PMID: 26248820 DOI: 10.1093/ejcts/ezv269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/23/2015] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES As the indication for antiplatelet medication expands, patients may be exposed to an increased risk of excessive blood loss when cardiac surgery is required. The optimal timing to stop acetylsalicylic acid (ASA) or ASA combined with clopidogrel (ASA+Clo) before surgery is the subject of controversy. METHODS A total of 1065 patients were selected from a prospective randomized study on the effect of a fibrin sealant application in coronary artery bypass graft surgery [Fibrin sealant Induced Blood Exposure Reduction study; REGISTRATION NUMBER NTR1386 (http://www.trialregister.nl)], and divided into three groups according to the use of antiplatelet medication within 10 days prior to surgery: (i) ASA only (n = 662), (ii) ASA+Clo (n = 290) or (iii) no antiplatelet medication (n = 113). To investigate if an optimal stop day could be established, we fitted a series of multiple linear regression models, one for each preoperative day (running from Day -10 up to -1). The specific day corresponding to the best fitting model (highest adjusted R(2), with blood loss in the first 48 h postoperatively as the dependent variable) was considered as the best estimate for the optimal stop day. Bootstrap analysis (1000 times) was performed to calculate the corresponding confidence interval. Furthermore, major adverse cardiovascular and cerebral events (MACCE) were evaluated. RESULTS We could not estimate an optimal stop day for patients using ASA or ASA+Clo prior to their operation. Last use of ASA on Day -2 or earlier significantly decreased the percentage of patients receiving platelet transfusions compared with continuation until surgery (7 vs 13% for Day -1, P = 0.007). In patients using ASA+Clo, this percentage was reduced from 41 to 10 (P < 0.001). There was no association between stop day and the occurrence of MACCE. CONCLUSIONS There is no clinically relevant effect on blood loss indicating an optimal stop day for ASA alone or in combination with Clo. Last use on Day -2 resulted in the reduction of percentage of patients receiving platelet transfusions, especially in the ASA+Clo group.
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Affiliation(s)
- Chantal L I Gielen
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Eline F Bruggemans
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Theo Stijnen
- Department of Medical Statistics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Giuseppe Tavilla
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Anneke Brand
- Sanquin Blood Bank, Leiden, Netherlands Department of Immunohematology and Blood Transfusion, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
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Siller-Matula JM, Petre A, Delle-Karth G, Huber K, Ay C, Lordkipanidzé M, De Caterina R, Kolh P, Mahla E, Gersh BJ. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:753-770. [DOI: 10.1177/2048872615585516] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Alexandra Petre
- Department of Cardiology, Medical University of Vienna, Austria
| | | | - Kurt Huber
- 3rd Medical Department of Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria
| | - Marie Lordkipanidzé
- Faculty of Pharmacy, University of Montreal; Research Center, Montreal Heart Institute, Canada
| | - Raffaele De Caterina
- Institute of Cardiology, ‘G d’Annunzio’ University – Chieti-Pescara, Chieti, Italy
| | - Philippe Kolh
- Department of Cardiothoracic Surgery, University Hospital of Liege, Belgium
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Austria
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, College of Medicine Rochester, USA
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Anderson K, Jupiter DC, Abernathy SW, Frazee RC. Should clopidogrel be discontinued before laparoscopic cholecystectomy? Am J Surg 2014; 208:926-31; discussion 930-1. [PMID: 25435299 DOI: 10.1016/j.amjsurg.2014.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The perioperative management of clopidogrel remains an area of controversy. METHODS An institutional review board-approved retrospective review of patients undergoing a laparoscopic cholecystectomy while on clopidogrel from 2008 to 2012 was performed. These patients were then matched with a nonclopidogrel cohort based on American Society of Anesthesiologists score and emergent or elective surgery. Intraoperative estimated blood loss, operative time, length of stay, and 30-day morbidity were compared. RESULTS Thirty-six clopidogrel and 36 control patient records were analyzed. There were no significant differences in age, body mass index, sex, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss averaged 50 mL in the clopidogrel group and 47 mL in the control group (P = nonsignificant). There were no significant differences in operative time, 30-day morbidity, or length of stay between the 2 groups. CONCLUSIONS Laparoscopic cholecystectomy performed on patients maintained on clopidogrel during the perioperative period did not produce an increase in blood loss, operative time, 30-day morbidity, or length of stay.
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Affiliation(s)
- Katherine Anderson
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | - Daniel C Jupiter
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | | | - Richard C Frazee
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA.
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Temporary adjunctive cilostazol vs clopidogrel loading for ST-segment elevation acute myocardial infarction. Am J Cardiovasc Drugs 2014; 14:131-6. [PMID: 24452598 DOI: 10.1007/s40256-013-0059-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clopidogrel loading is a standard method to achieve rapid platelet inhibition and prevent thrombotic events. At the current time, little information is available to determine the effect of adjunctive cilostazol compared with clopidogrel loading. METHODS We retrospectively analyzed 212 patients undergoing primary percutaneous coronary intervention with drug-eluting stents for ST-segment elevation acute myocardial infarction. All patients were administered aspirin (100 mg once a day) and clopidogrel (75 mg once a day). The patients were divided into two groups according to the presence (loading group, n = 100) or absence (cilostazol group, n = 112) of clopidogrel loading (300 mg). Patients in the cilostazol group were administered adjunctive cilostazol (100 mg twice a day) in place of clopidogrel loading. Patient characteristics, medications, and 30-day clinical outcomes were examined. RESULTS The mean duration of cilostazol administration in the cilostazol group was 6.2 ± 4.9 days from the time of primary coronary intervention. No significant difference was observed in major adverse cardiac events (cardiac death, definite stent thrombosis, and non-fatal myocardial infarction) between the loading group and the cilostazol group (9/100; 9.0 vs. 8/112; 7.1%, p = 0.62). Definite stent thrombosis was observed for two patients in the loading group and one patient in the cilostazol group. The occurrence ratio of bleeding events did not differ significantly between the two groups (9.0 vs. 5.4%, p = 0.30). CONCLUSION There was no significant difference in the incidence of major adverse cardiac events between temporary adjunctive cilostazol treatment and clopidogrel loading in ST-segment elevation acute myocardial infarction patients. Our findings suggest one potential of cilostazol.
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Continuing clopidogrel during elective total hip and knee arthroplasty: assessment of bleeding risk and adverse outcomes. J Arthroplasty 2014; 29:325-8. [PMID: 23856063 DOI: 10.1016/j.arth.2013.06.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 05/28/2013] [Accepted: 06/09/2013] [Indexed: 02/01/2023] Open
Abstract
Limited research assessing risks of continued clopidogrel perioperatively in patients undergoing elective orthopedic procedures exists. Patients that underwent elective primary or revision total knee arthroplasty (TKA) or total hip arthroplasty (THA) from 2007 to 2012 while taking clopidogrel at the time of surgical evaluation were retrospectively identified. Patient demographics, last dose of clopidogrel, intraoperative blood loss, blood transfusion, and presence of 30-day adverse cardiac events (ACE) were collected. Of 142 patients meeting criteria, 24 (16.9%) patients remained on clopidogrel perioperatively. Patients that continued clopidogrel were more likely to receive a blood transfusion within 24 hours of surgery (31.8% vs. 7.7%; P=0.004) and during hospitalization (37.5% vs. 15.3%; P=0.02), but the incidence of 30-day ACE was not significantly different. Continuation of clopidogrel perioperatively for elective THA or TKA should be carefully considered.
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Duc Vu T, Zaw MH, Chang G, Hu SLJ, Tay CWB, Ng CWQ, Chia DKA, Lee CN, Kofidis T. Is continuation of antiplatelets until coronary artery bypass safe in Asians? Asian Cardiovasc Thorac Ann 2014; 22:909-18. [DOI: 10.1177/0218492314521421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Controversies have arisen about the risks of discontinuing antiplatelets prior to coronary artery bypass grafting. Methods We retrospectively studied the effects of different strategies of antiplatelet discontinuation prior to coronary artery bypass on perioperative bleeding and major adverse cardiovascular events in Asian patients in a single center in Singapore. Results 402 patients were divided into 4 groups: group A had no antiplatelets before surgery; antiplatelets were stopped for 5–7 days in group B; 2–4 days in group C; and 0–1 day in group D. Compared to group B, group D had longer intensive care unit stays and more intraoperative transfusions of blood ( p = 0.006) and blood products ( p < 0.05). The 1-year major adverse cardiovascular event rate was higher in groups A and D ( p = 0.027). Stopping antiplatelets within 24 h of surgery was one of multiple independent predictors of intraoperative transfusion but not the 1-year major adverse cardiovascular event rate. Patients on aspirin alone had less intraoperative transfusion of platelets and postoperative minor bleeding than those on combined therapy. Conclusion Continuation of antiplatelets until 2 days before coronary artery bypass in Asian patients in our institution is unlikely to increase the risks of bleeding and perioperative transfusion. Taking antiplatelets within 24 h of surgery seems to be associated with a higher rate of 1-year major adverse cardiovascular events and bleeding, and an increased risk of blood product transfusion. Thirty-day and 1-year major adverse cardiovascular event rates were higher in patients without antiplatelet treatment.
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Affiliation(s)
- Thang Duc Vu
- Department of Surgery, National University of Singapore, Singapore
| | - Min Htet Zaw
- Department of Surgery, National University of Singapore, Singapore
| | - Guohao Chang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore
| | - Shu Lin Jesse Hu
- Department of Surgery, National University of Singapore, Singapore
| | - Chee Wei Bobby Tay
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore
| | - Celene Wei Qi Ng
- Department of Surgery, National University of Singapore, Singapore
| | - Daryl KA Chia
- Department of Surgery, National University of Singapore, Singapore
| | - Chuen Neng Lee
- Department of Surgery, National University of Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore
| | - Theo Kofidis
- Department of Surgery, National University of Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore
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Hijazi EM, Musleh GS. Clopidogrel Within Few Hours of Coronary Artery Bypass Grafting Does Significantly Increase the Risk of Bleeding. Cardiol Res 2012; 3:209-213. [PMID: 28348689 PMCID: PMC5358133 DOI: 10.4021/cr226e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 11/27/2022] Open
Abstract
Background Postoperative bleeding after coronary artery surgery is partly related to platelet dysfunction. The aim of this study was to evaluate the effects of a single loading dose of clopidogrel (300 mg) before coronary angiography on bleeding and use of blood and blood products after emergency coronary artery bypass surgery (CABG). Methods This is a nonrandomized observational prospective study between January, 2006 till December 2009, at a university hospital, we compare the results of a cohort of 65 patients who received 300 mg clopidogrel during coronary angiography that was followed by emergency CABG (group A or study group) to a cohort of 206 patients who underwent elective coronary artery bypass surgery during the same period by the same surgeons in whom clopidogrel was stopped 7 days before surgery (Group B or control group). Emergency surgery was done because of critical coronary anatomy or because of ongoing chest pain. All patients in the two groups were kept on 100 mg of aspirin until the day of surgery. Outcome data used to compare the two groups, Chest tube drainage in first 12 hours (12 h), need for re-exploration and use of blood and blood product transfusion were prospectively collected. Results Postoperative bleeding, reoperation rates for bleeding and use of blood products are significantly more in those who received a loading dose of clopedogril within few hours of CABG (group A) compared to those who stopped clopedogril for a week before CABG. Conclusions Preoperative 300 mg of clopidogrel is associated with significant increase in post operative bleeding, need for surgical exploration and use of blood and blood product transfusion after CABG.
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Affiliation(s)
- Emad M Hijazi
- Princess Muna AL-Hussein Cardiac Center, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Jordan
| | - Ghassan S Musleh
- Princess Muna AL-Hussein Cardiac Center, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Jordan
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Varenhorst C, Alström U, Scirica BM, Hogue CW, Åsenblad N, Storey RF, Steg PG, Horrow J, Mahaffey KW, Becker RC, James S, Cannon CP, Brandrup-Wognsen G, Wallentin L, Held C. Factors Contributing to the Lower Mortality With Ticagrelor Compared With Clopidogrel in Patients Undergoing Coronary Artery Bypass Surgery. J Am Coll Cardiol 2012; 60:1623-30. [DOI: 10.1016/j.jacc.2012.07.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 07/02/2012] [Accepted: 07/02/2012] [Indexed: 01/12/2023]
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Bleeding risk assessment using multiple electrode aggregometry in patients following coronary artery bypass surgery. J Thromb Thrombolysis 2012; 35:31-40. [DOI: 10.1007/s11239-012-0798-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Vorobcsuk A, Aradi D, Farkasfalvi K, Horváth IG, Komócsi A. Outcomes of patients receiving clopidogrel prior to cardiac surgery. Int J Cardiol 2012; 156:34-40. [DOI: 10.1016/j.ijcard.2010.10.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 10/23/2010] [Indexed: 10/18/2022]
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Biancari F, Airaksinen KEJ, Lip GY. 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 2012; 143:665-675.e4. [DOI: 10.1016/j.jtcvs.2011.01.069] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/04/2011] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
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Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e227S-e277S. [PMID: 22315263 PMCID: PMC3278061 DOI: 10.1378/chest.11-2297] [Citation(s) in RCA: 1385] [Impact Index Per Article: 115.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND VTE is a common cause of preventable death in surgical patients. METHODS We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations. CONCLUSIONS Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients.
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Affiliation(s)
- Michael K Gould
- Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - David A Garcia
- University of New Mexico School of Medicine, Albuquerque, NM
| | | | - Paul J Karanicolas
- Surgical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - John A Heit
- College of Medicine, Mayo Clinic, Rochester, MN
| | - Charles M Samama
- Department of Anaesthesiology and Intensive Care, Hotel-Dieu University Hospital, Paris, France
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Au AG, Majumdar SR, McAlister FA. Preoperative thienopyridine use and outcomes after surgery: a systematic review. Am J Med 2012; 125:87-99.e1. [PMID: 22079019 DOI: 10.1016/j.amjmed.2011.07.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 06/29/2011] [Accepted: 07/25/2011] [Indexed: 01/23/2023]
Abstract
BACKGROUND Although studies have demonstrated excess risk of ischemic events if aspirin is withheld preoperatively, it is unclear whether preoperative thienopyridine use influences postoperative outcomes. METHODS We conducted a systematic review of 37 studies (31 cardiac and 6 noncardiac surgery, 3 randomized, 34 observational) comparing postoperative outcomes in patients who were versus were not exposed to thienopyridine in the 5 days before surgery. RESULTS Exposure to thienopyridine in the 5 days preceding surgery (compared with no exposure) was not associated with any reduction in postoperative myocardial infarction (23 studies, 12,872 patients, 3.4% vs 3.0%, odds ratio [OR] 0.98; 95% confidence interval [CI], 0.72-1.34), but was associated with increased risks of stroke (16 studies, 10,265 patients, 1.9% vs 1.4%, OR 1.54; 95% CI, 1.08-2.20), reoperation for bleeding (32 studies, 19,423 patients, 4.3% vs 1.8%, OR 2.62; 95% CI, 1.96-3.49), and all-cause mortality (28 studies, 22,990 patients, 3.7% vs 2.6%, OR 1.38; 95% CI, 1.13-1.69). Results were identical when analyses were restricted to long-term users of thienopyridines who continued versus held the medication in the 5 days before surgery. Although all associations were similar in direction for the subset of patients undergoing noncardiac surgery, 97% of the outcome data in this meta-analysis came from cardiac surgery trials. CONCLUSIONS These data support withholding thienopyridines 5 days before cardiac surgery; there was insufficient evidence to make definitive recommendations for elective noncardiac surgery although the direction and magnitude of associations were similar.
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Affiliation(s)
- Anita G Au
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
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Abstract
Cushing's syndrome is a clinical situation, caused by excessive glucocorticoid level, resulting in several features such as central obesity, supraclavicular fat, "moon face," "buffalo hump," hyperglycemia, metabolic alkalosis, hypokalemia, poor wound healing, easy bruising, hypertension, proximal muscle weakness, thin extremities, skin thinning, menstrual irregularities, and purple striae. In the perioperative period, the anesthesiologist must deal with difficult ventilation and intubation, hemodynamic disturbances, volume overload and hypokalemia, glucose intolerance, and diabetes, maintaining the blood cortisol level and preventing the glucocorticoid deficiency. This syndrome is quite rare and its features make these patients very difficult to the anesthesiologist.
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Affiliation(s)
- Rudin Domi
- Department of Anesthesiology, Intensive Care, Emergency, and Toxicology, University Hospital Center “Mother Theresa”, Tirana, Albania
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Ferrandis R, Llau JV, Mugarra A. Perioperative management of antiplatelet-drugs in cardiac surgery. Curr Cardiol Rev 2011; 5:125-32. [PMID: 20436853 PMCID: PMC2805815 DOI: 10.2174/157340309788166688] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/11/2008] [Accepted: 08/11/2008] [Indexed: 11/30/2022] Open
Abstract
The management of coronary patients scheduled for a coronary artery bypass grafting (CABG), who are receiving one or more antiplatelet drugs, is plenty of controversies. It has been shown that withdrawal of antiplatelet drugs is associated with an increased risk of a thrombotic event, but surgery under an altered platelet function also means an increased risk of bleeding in the perioperative period. Because of the conflict recommendations, this review article tries to evaluate the outcome of different perioperative antiplatelet protocols in patients with coronary artery disease undergoing CABG.
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Affiliation(s)
- Raquel Ferrandis
- Department of Anaesthesiology and Critical Care Medicine, Hospital Clínic Universitari, València, Spain
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Nijjer SS, Watson G, Athanasiou T, Malik IS. 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 2011; 32:2970-88. [DOI: 10.1093/eurheartj/ehr151] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Don CW, Roe MT, Li S, Fraulo E, Pomerantsev E, Palacios I, Wiviott SD. Temporal trends and practice variations in clopidogrel loading doses in patients with non-ST-segment elevation myocardial infarction, from the National Cardiovascular Data Registry. Am Heart J 2011; 161:689-97. [PMID: 21473967 DOI: 10.1016/j.ahj.2010.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 12/21/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND A higher loading dose of clopidogrel achieves a more rapid and consistent degree of platelet inhibition than standard dosing, although the clinical benefit of higher doses has not been clearly established. The use of the different doses in clinical practice is not known. We evaluated the patient, procedural, and hospital characteristics associated clopidogrel loading doses given to patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS The National Cardiovascular Data Registry ACTION Get With the Guidelines Registry was queried for patients with NSTEMI admitted from 2007 to 2008. Demographic, clinical, and procedural information were collected on standardized data forms. Patients were categorized according to the clopidogrel loading dose received. Temporal trends in the use of different doses were evaluated in quarterly time intervals. RESULTS Between January 1, 2007, and December 31, 2008, the use of a 600-mg clopidogrel loading dose increased steadily from 36.4% to 45.5%, whereas the use of 300 mg decreased slightly from 40.1% to 37.1%. Patients loaded with clopidogrel before cardiac catheterization were more likely to receive 300 mg, whereas those receiving a loading dose at the time of catheterization more often received 600 mg. The temporal increase in the use of 600 mg clopidogrel loading doses was not explained by temporal changes in periprocedural loading, use of early invasive management of patients with NSTEMI, or use of antithrombotics or glycoprotein 2b/3a inhibitors. CONCLUSIONS Higher loading dose clopidogrel increased between 2007 and 2008. Higher-dose clopidogrel was more frequently used in lower-risk patients undergoing an early invasive strategy and receiving periprocedural loading.
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Liang YS, Mu S, Liu Y, Liu DK. ( R)-[1-(2-Chlorophenyl)-2-methoxy-2-oxoethyl][2-(thiophen-2-yl)ethyl]ammonium (+)-camphor-10-sulfonate acetone monosolvate. Acta Crystallogr Sect E Struct Rep Online 2010; 66:o3117. [PMID: 21589421 PMCID: PMC3011721 DOI: 10.1107/s160053681004523x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 11/04/2010] [Indexed: 11/12/2022]
Abstract
The title compound, C15H17ClNO2S+·C10H15O4S−·C3H6O, was synthesized by N-alkylation of α-amino-(2-chlorophenyl)acetate with 2-thienylethyl p-toluenesulfonate, followed by reaction with (+)-camphor-10-sulfonic acid. In the crystal, the cations and anions are linked through N—H⋯O hydrogen bonds. The thiophene ring of the cation was found to be disordered over two sites, with refined occupancies of 0.798 (4) and 0.202 (4).
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21
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Controversies in Oral Antiplatelet Therapy in Patients Undergoing Aortocoronary Bypass Surgery. Ann Thorac Surg 2010; 90:1040-51. [DOI: 10.1016/j.athoracsur.2010.04.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/08/2010] [Accepted: 04/09/2010] [Indexed: 11/20/2022]
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22
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Stewart LC, Langtry JAA. Clopidogrel: mechanisms of action and review of the evidence relating to use during skin surgery procedures. Clin Exp Dermatol 2010; 35:341-5. [DOI: 10.1111/j.1365-2230.2009.03539.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Clopidogrel Increases Blood Transfusion and Hemorrhagic Complications in Patients Undergoing Cardiac Surgery. Ann Thorac Surg 2010; 89:397-402. [DOI: 10.1016/j.athoracsur.2009.10.051] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Revised: 10/17/2009] [Accepted: 10/21/2009] [Indexed: 12/27/2022]
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24
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Abstract
Despite the prevalence of surgical candidates on clopidogrel, no definitive guidelines exist for stopping the drug preoperatively. A 7 day off-clopidogrel period is commonly considered safe with regards to bleeding complications. We sought to put the 7-day window to the test with regards to major bleeding events requiring either blood transfusions or return trips to the operating room. We collected data for patients taking clopidogrel in the perioperative period between 2005 and 2007 (n = 170). This data was then compared with the data of all of the patients undergoing surgery at our institution for the same time period (n = 34,480). Patients taking clopidogrel experienced a significantly higher rate of return trips to the operating room (6.5%) compared with nonclopidogrel patients (0.015%). Interestingly, we found no significant difference between those stopping clopidogrel more than 7 days preoperatively and those that did not (5% and 7.5%, respectively). There did not seem to be a significant difference in blood transfusion rates between the two clopidogrel groups. Patients on perioperative clopidogrel require reoperations for bleeding at a significantly higher rate compared with patients not taking clopidogrel. Discontinuing clopidogrel 7 days before surgery is not enough to negate this difference and these patients still experience a drastically higher rate of reoperations for bleeding.
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Affiliation(s)
- Dejan Grujic
- From the Huntington Memorial Hospital, Pasadena, California
| | - David Martin
- From the Huntington Memorial Hospital, Pasadena, California
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25
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Possibility of a rebound phenomenon following antiplatelet therapy withdrawal: A look at the clinical and pharmacological evidence. Pharmacol Ther 2009; 123:178-86. [DOI: 10.1016/j.pharmthera.2009.03.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 03/20/2009] [Indexed: 02/02/2023]
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26
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Elefteriades JA. "How I do it: utilization of high-pressure sealants in aortic reconstruction". J Cardiothorac Surg 2009; 4:27. [PMID: 19558685 PMCID: PMC2708158 DOI: 10.1186/1749-8090-4-27] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 06/26/2009] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Suture-line hemostasis, reinforcement of friable tissue, and adhesion prevention are key concerns for patients undergoing cardiac surgery for aortic reconstruction. Failure to secure hemostasis at anastomotic junctures and reinforce fragile tissue may lead to increased blood loss, additional blood product requirements, increased operative time, and, in extreme cases, reoperation. Patients with aortic pathology may also be at higher risk for reoperation, and adhesion formation from prior surgery is an added risk at resternotomy. The advent of high-pressure sealants has been of benefit in helping to alleviate these perioperative challenges. METHODS The author utilizes two high-pressure sealants for aortic reconstructive procedures. The first is made of two polymers of polyethylene glycol (PEG) [Coseal, Baxter Healthcare, Corporation], and is used to secure anastomotic suture-line hemostasis and for adhesion prevention. The second is a bovine serum albumin-glutaraldehyde (BSAG) glue [BioGlue, CryroLife, Inc.], used for the repair of dissected aortic tissue and in reinforcing ("tanning") fragile aortic tissues. The techniques for application in select aortic reconstruction procedures are described. RESULTS To substantiate the hemostatic clinical benefit observed by the author, 60 consecutive major thoracic aortic operations in 57 patients in whom PEG sealant was used were retrospectively reviewed. Although comparisons with other agents were not performed for this descriptive report, bleeding results were very favorable for these types of operations. The strong clinical impression is that topical hemostatic application of PEG sealant to anastomotic suture lines is helpful in preventing bleeding. CONCLUSION In major aortic reconstructive procedures the need for anastomotic sealing performance, reinforcement of friable tissues, and adhesion prevention should not be underrated. High-pressure surgical sealants represent an important surgical adjunct, and the author has found the use of both PEG sealant and BSAG glue advantageous in aortic reconstruction and repair.
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Affiliation(s)
- John A Elefteriades
- Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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27
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Patel JH, Stoner JA, Owora A, Mathew ST, Thadani U. Evidence for using clopidogrel alone or in addition to aspirin in post coronary artery bypass surgery patients. Am J Cardiol 2009; 103:1687-93. [PMID: 19539077 DOI: 10.1016/j.amjcard.2009.02.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 02/05/2009] [Accepted: 02/05/2009] [Indexed: 10/20/2022]
Abstract
Clopidogrel is recommended with aspirin for patients who undergo coronary artery bypass grafting (CABG) after non-ST elevation myocardial infarctions. Cardiothoracic surgeons widely use clopidogrel in addition to aspirin for post-CABG patients, including those with stable coronary artery disease. The aim of this study was to systematically review the published research to determine whether clopidogrel use after CABG is based on good trial data. Studies reporting safety and/or efficacy data for clopidogrel use with or without aspirin after on- or off-pump CABG were included. Fourteen studies met the inclusion criteria, of which 11 were reported trials and 3 are ongoing trials. Subgroup retrospective analyses of previously reported large trials of patients presenting with acute coronary syndromes (n = 1) or patients with stable coronary artery disease (n = 3) did not show a clear clinical benefit of clopidogrel when given in addition to aspirin after CABG. In contrast, there was a trend toward increased major and minor bleeding after the use of clopidogrel plus aspirin. Two small prospective trials providing data on surrogate end points and 5 small trials involving off-pump CABG patients were not of good quality to draw meaningful conclusions. In conclusion, summarized data based on subgroup analyses, surrogate end points, and observational cohort studies fail to demonstrate a clear beneficial effect of clopidogrel alone or in combination with aspirin on clinical outcomes after CABG.
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Abstract
Antiplatelet agents like aspirin and clopidogrel are treatment cornerstones for acute coronary syndromes (ACS). Drawbacks of dual therapy with these agents include slow onset and offset of effect and wide response variability. Clopidogrel may provide little benefit if administered too close to percutaneous coronary intervention (PCI) and increase major bleeding risk if given too close to coronary artery bypass grafting (CABG) or other surgery. It may not provide sufficient antiplatelet coverage prior to CABG if stopped too long before intervention and leave patients without antiplatelet coverage due to hyporesponsiveness. Prasugrel has made steps towards addressing these limitations by exhibiting more efficient metabolism, more rapid onset of effect, and greater and more consistent platelet inhibition than clopidogrel. The TRITON-TIMI38 trial in ACS patients undergoing PCI showed prasugrel produced greater ischemic event protection than clopidogrel but significantly increased major bleeding risk. AZD6140, the first reversible oral P2Y(12) inhibitor, provides more rapid onset of effect and greater and more consistent platelet inhibition than clopidogrel. In DISPERSE2, a phase II trial in ACS patients, AZD6140 did not increase bleeding risk, reduced bleeding risk among CABG patients, and produced numerical reductions in myocardial infarction risk. AZD6140 is being compared with clopidogrel in PLATO, a phase III trial in approximately 18000 ACS patients.
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Affiliation(s)
- Steen Husted
- Department of Medicine and Cardiology, Arhus University Hospital, DK-8000 Arhus C, Arhus, Denmark.
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29
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Kulik A, Chan V, Ruel M. Antiplatelet therapy and coronary artery bypass graft surgery: perioperative safety and efficacy. Expert Opin Drug Saf 2009; 8:169-82. [DOI: 10.1517/14740330902797081] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Bae JP, Dobesh PP, McCollam PL, Khoynezhad A. Potential unrecognised costs of clopidogrel pretreatment in acute coronary syndrome. J Med Econ 2009; 12:325-30. [PMID: 19824808 DOI: 10.3111/13696990903352271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine adherence in clinical practice to the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations of observing a 5-day waiting period after clopidogrel administration before undergoing coronary artery bypass graft (CABG) surgery and to examine the costs of waiting. METHODS This retrospective study used a nationwide inpatient database (Solucient ACTracker) to identify patients who were admitted for acute coronary syndrome (ACS), and who had same-stay CABG. Cost of additional days of stay was estimated using regression analysis. RESULTS The recommended 5-day waiting was adhered to in 16.9% (n=3,809) of patients. The percentage of patients with ACS undergoing CABG surgery on day 0 was 14.6%. Adherence to the waiting was higher for teaching and rural hospitals; and in female and elderly patients and urgent admissions. CONCLUSIONS The recommended 5-day waiting for CABG surgery after clopidogrel treatment is poorly adhered to in clinical practice. This study was unable to determine specific reasons for the low adherence; however, there may be a compromise between the clinically urgent need for revascularisation and increased risk of bleeding, as well as economic costs associated with waiting. The cost of an additional hospital day in this group of patients was approximately £1,400 per day or £7,000 for 5 days. Thus, a full 5-day wait would have a significant economic impact on hospital costs.
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Affiliation(s)
- Jay P Bae
- Eli Lilly and Company, Indianapolis, IN, USA
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31
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DiMaria-Ghalili RA. Nutrition Risk Factors in Older Coronary Artery Bypass Graft Patients. Nutr Clin Pract 2008; 23:494-500. [DOI: 10.1177/0884533608323428] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ozao-Choy J, Tammaro Y, Fradis M, Weber K, Divino CM. Clopidogrel and Bleeding after General Surgery Procedures. Am Surg 2008. [DOI: 10.1177/000313480807400809] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix®) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions ( P = 0.12, 0.53), decreases in hematocrit ( P = 0.21), hospital stay ( P = 0.09), intensive care unit stay ( P = 0.41), late complications ( P = 0.45), or mortality ( P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.
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Affiliation(s)
- Junko Ozao-Choy
- From the Department of Surgery, The Mount Sinai School of Medicine, New York, New York
| | - Yolanda Tammaro
- From the Department of Surgery, The Mount Sinai School of Medicine, New York, New York
| | - Martin Fradis
- From the Department of Surgery, The Mount Sinai School of Medicine, New York, New York
| | - Kaare Weber
- From the Department of Surgery, The Mount Sinai School of Medicine, New York, New York
| | - Celia M. Divino
- From the Department of Surgery, The Mount Sinai School of Medicine, New York, New York
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33
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Becker RC. Emerging constructs to maintain safety among patients with acute coronary syndromes requiring surgical coronary revascularization. Eur Heart J Suppl 2008. [DOI: 10.1093/eurheartj/sun006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Widimsky P, Motovská Z, Simek S, Kala P, Pudil R, Holm F, Petr R, Bílková D, Skalická H, Kuchynka P, Poloczek M, Miklík R, Maly M, Aschermann M. Clopidogrel pre-treatment in stable angina: for all patients > 6 h before elective coronary angiography or only for angiographically selected patients a few minutes before PCI? A randomized multicentre trial PRAGUE-8. Eur Heart J 2008; 29:1495-503. [PMID: 18441320 PMCID: PMC2429977 DOI: 10.1093/eurheartj/ehn169] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS To compare two different clopidogrel regimens on the outcomes of patients undergoing elective coronary angiography (CAG)+/-ad hoc percutaneous coronary intervention (PCI). METHODS AND RESULTS Open-trial randomized 1028 patients with stable angina to group A ('non-selective'-clopidogrel 600 mg > 6 h before CAG; n = 513) or group B ('selective'-clopidogrel 600 mg in the cath-lab after CAG, only in case of PCI; n = 515). Combined primary endpoint was death/periprocedural myocardial infarction (MI)/stroke/re-intervention within 7 days. Secondary endpoints were troponin elevation and bleeding complications. Primary endpoint occurred in 0.8% group A patients vs. 1% group B (P = 0.749; 90% CI for the percentage difference -1.2-0.8). Periprocedural troponin elevation (> 3 x ULN) was detected in 2.6% group A vs. 3.3% group B (P = 0.475; 90% CI -2.5-1.0). Bleeding complications occurred in 3.5% group A patients vs. 1.4% group B (P = 0.025). After adjustment for covariates and factors that may influence the bleeding risk, patients in group A were shown to have more likely bleeding complications when compared with group B (OR = 3.03; 95% CI 1.14-8.10; P = 0.027). CONCLUSION High (600 mg) loading dose of clopidogrel before elective CAG increased the risk of minor bleeding complications, while the benefit on periprocedural infarction was not significant. Clopidogrel can be given safely in the catheterization laboratory between CAG and PCI in chronic stable angina patients.
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Affiliation(s)
- Petr Widimsky
- Third Medical Faculty and University Hospital Kralovske Vinohrady, Cardiocentre, Charles University, Srobárova 50, 10034 Praha 10, Prague, Czech Republic.
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Reynolds MW, Clark J, Crean S, Samudrala S. Risk of bleeding in surgical patients treated with topical bovine thrombin sealants: a review of the literature. Patient Saf Surg 2008; 2:5. [PMID: 18348725 PMCID: PMC2276484 DOI: 10.1186/1754-9493-2-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Accepted: 03/18/2008] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND One of the most anticipated, but potentially serious complications during or after surgery are bleeding events. Among the many potential factors associated with bleeding complications in surgery, the use of bovine thrombin has been anecdotally identified as a possible cause of increased bleeding risk. Most of these reports of bleeding events in association with the use of topical bovine thrombin have been limited to case reports lacking clear cause and effect relationship determination. Recent studies have failed to establish significant differences in the rates of bleeding events between those treated with bovine thrombin and those treated with either human or recombinant thrombin. METHODS We conducted a search of MEDLINE for the most recent past 10 years (1997-2007) and identified all published studies that reported a study of surgical patients with a clear objective to examine the risk of bleeding events in surgical patients. We also specifically noted the reporting of any topical bovine thrombin used during surgical procedures. We aimed to examine whether there were any differences in the risk of bleeds in general surgical populations as compared to those studies that reported exposure to topical bovine thrombin. RESULTS We identified 21 clinical studies that addressed the risk of bleeding in surgery. Of these, 5 studies analyzed the use of bovine thrombin sealants in surgical patients. There were no standardized definitions for bleeding events employed across these studies. The rates of bleeds in the general surgery studies ranged from 0.1%-20.2%, with most studies reporting rates between 2.6%-4%. The rates of bleeding events ranged from 0.0%-13% in the bovine thrombin studies with most studies reporting between a 2%-3% rate. CONCLUSION The risk of bleeds was not clearly different in those studies reporting use of bovine thrombin in all patients compared to the other surgical populations studied. A well-designed and well-controlled study is needed to accurately examine the bleeding risks in surgical patients treated and unexposed to topical bovine thrombin, and to evaluate the independent risk associated with topical bovine thrombin as well as other risk factors.
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Affiliation(s)
- Matthew W Reynolds
- Epidemiology and Database Services, United BioSource Corporation, Medford, MA, USA.
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36
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Pickard AS, Becker RC, Schumock GT, Frye CB. Clopidogrel-Associated Bleeding and Related Complications in Patients Undergoing Coronary Artery Bypass Grafting. Pharmacotherapy 2008; 28:376-92. [DOI: 10.1592/phco.28.3.376] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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