Clopidogrel loading dose and bleeding outcomes in patients undergoing urgent coronary artery bypass grafting

Background Coronary artery bypass grafting (CABG) performed within 5 days of clopidogrel administration is associated with increased bleeding. The impact of clopidogrel loading dose is unknown. We examined the effect of clopidogrel loading dose on bleeding outcomes in patients undergoing urgent CABG...

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Bibliographic Details
Published in:The American heart journal 2011-02, Vol.161 (2), p.404-410
Main Authors: Cruden, Nicholas L.M., PhD, MBChB, MRCP, Morch, Kristin, Wong, Daniel R., MD, MPH, FRCSC, Klinke, W. Peter, MD, FRCPC, Ofiesh, John, MD, FRCSC, Hilton, J. David, MD, FRCPC
Format: Article
Language:English
Subjects:
Acute coronary syndromes
Aged
Biological and medical sciences
Blood platelets
Blood pressure
Cardiology. Vascular system
Cardiovascular
Clinical outcomes
Coronary Artery Bypass
Coronary heart disease
Coronary vessels
Drug therapy
Emergency Treatment
Female
Heart
Heart attacks
Heart surgery
Hemorrhage - chemically induced
Hemorrhage - epidemiology
Humans
Male
Medical sciences
Middle Aged
Mortality
Platelet Aggregation Inhibitors - administration & dosage
Platelet Aggregation Inhibitors - adverse effects
Retrospective Studies
Statistical analysis
Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases
Surgery of the heart
Ticlopidine - administration & dosage
Ticlopidine - adverse effects
Ticlopidine - analogs & derivatives
Veins & arteries
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Summary:Background Coronary artery bypass grafting (CABG) performed within 5 days of clopidogrel administration is associated with increased bleeding. The impact of clopidogrel loading dose is unknown. We examined the effect of clopidogrel loading dose on bleeding outcomes in patients undergoing urgent CABG. Methods Clinical outcomes were examined retrospectively for 196 consecutive patients undergoing urgent CABG within 5 days of a clopidogrel loading dose between January 2003 and June 2009. Major bleeding was defined as a fall in hemoglobin >5g/dL, fatal or intracranial bleeding, or cardiac tamponade. Results One hundred forty-eight patients received 300 mg and 48 patients received ≥600 mg clopidogrel loading. Patients were predominantly male (78%) with a mean age of 66 ± 10 years. Mean duration from clopidogrel loading to CABG was 3.0 ± 1.5 and 3.0 ± 1.6 days for the 300 and 600 mg loading doses, respectively. Major bleeding occurred in 47% of patients receiving 300 mg and 73% of patients receiving ≥600 mg clopidogrel loading ( P = .002). Compared with 300 mg, patients receiving ≥600 mg had greater 24-hour chest tube output (391 ± 251 vs 536 ± 354 mL, P = .01), stayed longer in surgical intensive care (4.3 ± 4.1 vs 5.0 ± 3.1 days, P = .0001), and trended toward greater reoperation for bleeding (5% vs 12%, P = .09). Following multivariate analysis, clopidogrel loading dose ≥600 mg (odds ratio 2.8, CI 1.2-6.6), preoperative hemoglobin (3.4, 2.7-5.0 per 1 g/dL increase), and female gender (2.9, 1.1-7.4) predicted major bleeding. Conclusions Higher clopidogrel loading doses are associated with increased bleeding when administered within 5 days of CABG. The development of shorter-acting, reversible, oral antiplatelet agents may reduce perioperative bleeding in this population.
ISSN:0002-8703
1097-6744
DOI:10.1016/j.ahj.2010.10.037