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CLINICAL RESEARCH: ACUTE CORONARY SYNDROME

Acute Clopidogrel Use and Outcomes in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Artery Bypass Surgery

Rajendra H. Mehta, MD, MS, FACC^_*,_*, Matthew T. Roe, MD, MHS, FACC^_*, Jyotsna Mulgund, MS^_*, E. Magnus Ohman, MD, FACC, Christopher P. Cannon, MD, FACC, W. Brian Gibler, MD, Charles V. Pollack, Jr, MD, MA^||, Sidney C. Smith, Jr, MD, FACC, T. Bruce Ferguson, MD^¶ and Eric D. Peterson, MD, MPH, FACC^_*

^_* Division of Cardiology and the Duke Clinical Research Institute, Durham, North Carolina
University of North Carolina School of Medicine, Chapel Hill, North Carolina
TIMI Study Group, Brigham and Women’s Hospital, Boston, Massachusetts
University of Cincinnati College of Medicine, Cincinnati, Ohio
^|| University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
^¶ Louisiana State University Health Science Center, New Orleans, Louisiana.

Manuscript received August 30, 2005; revised manuscript received March 17, 2006, accepted March 21, 2006.

^_* Reprint requests and correspondence: Dr. Rajendra H. Mehta, Box 17969, Duke Clinical Research Institute, Durham, North Carolina 27715. (Email: mehta007{at}dcri.duke.edu).

OBJECTIVES: We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting (CABG) and examine the drug’s impact on risks for postoperative transfusions among patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS).

BACKGROUND: Adherence in community practice to American College of Cardiology/American Heart Association guidelines for clopidogrel use among NSTE ACS patients has not been previously characterized.

METHODS: We evaluated 2,858 NSTE ACS patients undergoing CABG at 264 hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. We examined the patterns of acute clopidogrel therapy and its association with bleeding risks among those having "early" CABG 5 days and again among those having "late" surgery >5 days after catheterization.

RESULTS: Within 24 h of admission, 852 patients (30%) received clopidogrel. In contrast to national guidelines, 87% of clopidogrel-treated patients underwent CABG 5 days after treatment. Among those receiving CABG within 5 days of last treatment, the use of clopidogrel was associated with a significant increase in blood transfusions (65.0% vs. 56.9%, adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.10 to 1.68) as well as the need for transfusion of 4 U of blood (27.7% vs. 18.4%, OR 1.70, 95% CI 1.32 to 2.19). In contrast, acute clopidogrel therapy was not associated with higher bleeding risks if CABG was delayed >5 days (adjusted OR 1.18, 95% CI 0.54 to 2.58).

CONCLUSIONS: Despite guideline recommendations, the overwhelming majority of NSTE ACS patients treated with acute clopidogrel needing CABG have their surgery within 5 days of treatment. A failure to delay surgery is associated with increased blood transfusion requirements that must be weighed against the potential clinical and economic impacts of such delays.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   CABG = coronary artery bypass graft   CI = confidence interval   CRUSADE = Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines Initiative   CURE = Clopidogrel in Unstable Angina to Prevent Recurrent Events trial   GP = glycoprotein   NSTE ACS = non–ST-segment elevation acute coronary syndromes   OR = odds ratio   RBC = red blood cell   RR = relative risk

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