Clopidogrel in ACS and CABG Clopidogrel in ACS and CABG Surgery Surgery m JH, et al m JH, et al . Am Heart J. . Am Heart J. 2008 Nov;156(5):886-92 2008 Nov;156(5):886-92 Clopidogrel use and bleeding after Clopidogrel use and bleeding after coronary artery bypass graft surgery coronary artery bypass graft surgery John Hyung-Jun Kim, MD, MBA, a,b L. Kristin Newby, MD, MHS, b,c Robert M. John Hyung-Jun Kim, MD, MBA, a,b L. Kristin Newby, MD, MHS, b,c Robert M. Clare, MS, b Linda K. Shaw, MS, b Andrew J. Lodge, MD, d Peter K. Smith, Clare, MS, b Linda K. Shaw, MS, b Andrew J. Lodge, MD, d Peter K. Smith, MD, d E. Marc Jolicoeur, MD, MS, b Sunil V. Rao, MD, b,c Richard C. MD, d E. Marc Jolicoeur, MD, MS, b Sunil V. Rao, MD, b,c Richard C. Becker, MD, b,c Daniel B. Mark, MD, MPH, b,c and Christopher B. Granger, Becker, MD, b,c Daniel B. Mark, MD, MPH, b,c and Christopher B. Granger, MD b,c Palo Alto, CA; and Durham, NC MD b,c Palo Alto, CA; and Durham, NC Am Heart J. Am Heart J. 2008 Nov;156(5):886-92 2008 Nov;156(5):886-92
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Clopidogrel in ACS and CABG Surgery Kim JH, et al. Am Heart J. 2008 Nov;156(5):886-92 Clopidogrel use and bleeding after coronary artery bypass graft surgery.
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Clopidogrel in ACS and CABG SurgeryClopidogrel in ACS and CABG Surgery
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Clopidogrel use and bleeding after Clopidogrel use and bleeding after coronary artery bypass graft surgery coronary artery bypass graft surgery
John Hyung-Jun Kim, MD, MBA, a,b L. Kristin Newby, MD, MHS, b,c Robert M. Clare, MS, b Linda John Hyung-Jun Kim, MD, MBA, a,b L. Kristin Newby, MD, MHS, b,c Robert M. Clare, MS, b Linda K. Shaw, MS, b Andrew J. Lodge, MD, d Peter K. Smith, MD, d E. Marc Jolicoeur, MD, MS, b Sunil K. Shaw, MS, b Andrew J. Lodge, MD, d Peter K. Smith, MD, d E. Marc Jolicoeur, MD, MS, b Sunil
V. Rao, MD, b,c Richard C. Becker, MD, b,c Daniel B. Mark, MD, MPH, b,c and Christopher B. V. Rao, MD, b,c Richard C. Becker, MD, b,c Daniel B. Mark, MD, MPH, b,c and Christopher B. Granger, MD b,c Palo Alto, CA; and Durham, NCGranger, MD b,c Palo Alto, CA; and Durham, NC
Am Heart J. Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Changing the Calculations for Assessing Guidelines Adherence
Anderson HV, Bach RG, J Am Coll Cardiol 2005;46:1488-9.Anderson HV, Bach RG, J Am Coll Cardiol 2005;46:1488-9. Anderson HV, Bach RG, J Am Coll Cardiol 2005;46:1488-9.Anderson HV, Bach RG, J Am Coll Cardiol 2005;46:1488-9.
“We need to invert the current equation to calculate an opportunity score for ACS patients rather than a risk score. Patients with higher baseline risks, such as the elderly, would have higher opportunity scores for benefit, even allowing for some of the greater risks from the treatment.”
“We need to invert the current equation to calculate an opportunity score for ACS patients rather than a risk score. Patients with higher baseline risks, such as the elderly, would have higher opportunity scores for benefit, even allowing for some of the greater risks from the treatment.”
I-A recommendation for upstream advanced anti-platelet therapy in high-risk ACS
Clopidogrel straightforward, well-supported● What about bleeding risk and CABG surgery?● New observational study
I-A recommendation for upstream advanced anti-platelet therapy in high-risk ACS
Clopidogrel straightforward, well-supported● What about bleeding risk and CABG surgery?● New observational study
Upstream Antiplatelet Therapy: Bottom Line
Clopidogrel in ASC and CABG SurgeryClopidogrel in ASC and CABG Surgery
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
► Background: Background: Short-term use of clopidogrel plus aspirin among Short-term use of clopidogrel plus aspirin among patients with acute coronary syndrome reduces ischemic events, patients with acute coronary syndrome reduces ischemic events, but concerns about coronary artery bypass graft (CABG) surgery–but concerns about coronary artery bypass graft (CABG) surgery–related bleeding limit its early use. What does new data show?related bleeding limit its early use. What does new data show?
► Methods: Methods: Using data from 4,794 consecutive CABG procedures in Using data from 4,794 consecutive CABG procedures in the Duke Databank for Cardiovascular Disease , investigators the Duke Databank for Cardiovascular Disease , investigators developed multivariable models for associations with CABG-related developed multivariable models for associations with CABG-related bleeding defined as reoperation for bleeding, red cell transfusion, bleeding defined as reoperation for bleeding, red cell transfusion, and a composite of reoperation/transfusion/ hematocrit drop ≥15%. and a composite of reoperation/transfusion/ hematocrit drop ≥15%.
► Study examined clopidogrel use ≤5 days versus no clopidogrel ≤5 Study examined clopidogrel use ≤5 days versus no clopidogrel ≤5 days before CABG in each model. Models were adjusted for days before CABG in each model. Models were adjusted for propensity for clopidogrel use ≤5 days. propensity for clopidogrel use ≤5 days.
Clopidogrel in ACS and CABG SurgeryClopidogrel in ACS and CABG Surgery
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
► Results: Results: Among the 4,794 CABG patients:Among the 4,794 CABG patients:
● 332 (6.9%) received clopidogrel ≤5 days before CABG332 (6.9%) received clopidogrel ≤5 days before CABG● 127 (2.6%) had reoperation for bleeding127 (2.6%) had reoperation for bleeding● 3,277 (68.4%) received red cell transfusion3,277 (68.4%) received red cell transfusion● 4,387 (91.5%) had the composite outcome. 4,387 (91.5%) had the composite outcome.
► After adjustment, clopidogrel use ≤5 days was not significantly After adjustment, clopidogrel use ≤5 days was not significantly associated with reoperation (odds ratio [OR] 1.24, 95% CI 0.63-2.41) associated with reoperation (odds ratio [OR] 1.24, 95% CI 0.63-2.41) or the composite bleeding end point (OR 1.23, 95% CI 0.72-2.10). or the composite bleeding end point (OR 1.23, 95% CI 0.72-2.10).
► Clopidogrel ≤5 days was modestly associated with red cell Clopidogrel ≤5 days was modestly associated with red cell transfusion (OR 1.40, 95% CI 1.04-1.89) but more weakly than transfusion (OR 1.40, 95% CI 1.04-1.89) but more weakly than other factors, including which surgeon performed the procedure. other factors, including which surgeon performed the procedure.
Bleeding End Point Rates by Bleeding End Point Rates by Timing of Clopidogrel UseTiming of Clopidogrel Use
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Model of Reoperation for BleedingMultivariable Model of Reoperation for Bleeding(Clopidogrel and Propensity for Clopidogrel Forced In)(Clopidogrel and Propensity for Clopidogrel Forced In)
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Model of Composite Bleeding EndpointMultivariable Model of Composite Bleeding Endpoint(Clopidogrel and Propensity for Clopidogrel Forced In)(Clopidogrel and Propensity for Clopidogrel Forced In)
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Model of Composite Bleeding EndpointMultivariable Model of Composite Bleeding Endpoint(continued)(continued)
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Model of Packed Multivariable Model of Packed Red Blood Cell TransfusionRed Blood Cell Transfusion
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Model of Packed Multivariable Model of Packed Red Blood Cell Transfusion (cont.)Red Blood Cell Transfusion (cont.)
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Linear Model of Number of Units Multivariable Linear Model of Number of Units of Packed Red Blood Cell Transfusionof Packed Red Blood Cell Transfusion
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Multivariable Linear Model of Number of Units Multivariable Linear Model of Number of Units of Packed Red Blood Cell Transfusion (cont.)of Packed Red Blood Cell Transfusion (cont.)
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
Study ConclusionsStudy Conclusions
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
► Conclusion: Conclusion: Clopidogrel administration ≤5 days before Clopidogrel administration ≤5 days before CABG was not significantly associated with reoperation CABG was not significantly associated with reoperation for bleeding or a bleeding composite, and only weakly for bleeding or a bleeding composite, and only weakly with red cell transfusion after surgery. with red cell transfusion after surgery.
► Clinical Implication:Clinical Implication: The impact of withholding The impact of withholding clopidogrel acutely in those for whom clopidogrel has clopidogrel acutely in those for whom clopidogrel has proven benefits and the impact of delaying CABG to proven benefits and the impact of delaying CABG to prevent bleeding among patients treated with clopidogrel prevent bleeding among patients treated with clopidogrel should be viewed in the context of other stronger should be viewed in the context of other stronger determinants of bleeding. determinants of bleeding.
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
► Lack of a clear pattern of transfusion frequency with Lack of a clear pattern of transfusion frequency with timing of CABG since the last clopidogrel dose suggests timing of CABG since the last clopidogrel dose suggests that factors other than a biological effect of clopidogrel that factors other than a biological effect of clopidogrel contribute to transfusion use. contribute to transfusion use.
► Overall high rates of transfusion observed in our single- Overall high rates of transfusion observed in our single- center study and the comparable high rates of center study and the comparable high rates of transfusion in the CRUSADE registry and other reported transfusion in the CRUSADE registry and other reported experiences suggest that rather than focus on a single experiences suggest that rather than focus on a single drug, a concerted, prospective effort should be drug, a concerted, prospective effort should be undertaken to understand the general drivers of undertaken to understand the general drivers of transfusion and ascertain what can be done to decrease transfusion and ascertain what can be done to decrease rates of blood transfusion after heart surgery.rates of blood transfusion after heart surgery.
Study ConclusionsStudy Conclusions
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
► With careful analysis of baseline characteristics, With careful analysis of baseline characteristics, concomitant medication use, type of procedure and concomitant medication use, type of procedure and surgeon, surgeon, clopidogrel administration ≤5 days before CABG clopidogrel administration ≤5 days before CABG was not significantly associated with reoperation for was not significantly associated with reoperation for bleeding or a composite measure of bleeding.bleeding or a composite measure of bleeding.
► Clopidogrel was more weakly associated with Clopidogrel was more weakly associated with perioperative red cell transfusion than other factors. perioperative red cell transfusion than other factors.
Study ConclusionsStudy Conclusions
Kim JH, et alKim JH, et al. Am Heart J. . Am Heart J. 2008 Nov;156(5):886-922008 Nov;156(5):886-92
►Impact of withholding clopidogrel acutely in ACS patients Impact of withholding clopidogrel acutely in ACS patients or of delaying CABG to prevent bleeding among or of delaying CABG to prevent bleeding among clopidogrel-treated patients should be viewed in the clopidogrel-treated patients should be viewed in the context of managing other stronger determinants of context of managing other stronger determinants of bleeding.bleeding.
►An aggressive effort to understand and limit high rates of An aggressive effort to understand and limit high rates of transfusion use may be more important overall than transfusion use may be more important overall than continued focus on the effects of a single drug. continued focus on the effects of a single drug.