Should clopidogrel be stopped prior to urgent cardiac
surgery?
Babu Kunadian 1,
Andrew R. Thornley 1,
Marios Tanos 2,
Joel Dunning 1*
1 James Cook University Hospital, Middlesbrough, UK
2 Freeman Hospital, Newcastle-upon-Tyne, UK
* To whom correspondence should be addressed. E-mail: joeldunning{at}doctors.org.uk.
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Abstract |
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel should be stopped prior to urgent cardiac surgery. Altogether 143 papers were identified using the below mentioned search and all major international guidelines were included. 14 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that there are 2 issues to address when considering this topic. Firstly whether recent clopidogrel administration causes an increase in blood loss during cardiac surgery, and secondly whether there is a risk to the patient of withholding clopidogrel and delaying surgery. In answer to the first issue, a meta-analysis of 11 cohort studies and also many additional papers have clearly been shown that recent clopidogrel administration within 5-7 days of surgery is associated with an increased chest drainage of 30-100%, an increase in blood product usage and a 2-5 times increase in the need for re-exploration. However data from the multicentre prospective randomized controlled trials that provide the evidence in favour of clopidogrel in patients admitted with NSTEMI, acute coronary syndrome or requiring PCI also shows that withholding clopidogrel prior to a revascularisation intervention is associated with a 1% increase in the risk of myocardial infarction. Despite this small increased risk, the American College of Cardiology recommend withholding clopidogrel for 5-7 days when clinically feasible. Keywords: Evidence-based medicine; Clopidogrel; Thoracic surgery; Antiplatelet therapy; Reoperation; Post-operative bleeding
