CLINICAL RESEARCH: ACUTE CORONARY SYNDROMES
Outcomes Following Pre-Operative Clopidogrel Administration in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass SurgeryThe ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) Trial
Ramin Ebrahimi, MD*,*,
Cornelius Dyke, MD ,
Roxana Mehran, MD ,
Steven V. Manoukian, MD ,
Frederick Feit, MD||,
David A. Cox, MD¶,
Bernard J. Gersh, MB, ChB, DPhil#,
E. Magnus Ohman, MD**,
Harvey D. White, MD ,
Jeffrey W. Moses, MD ,
James H. Ware, PhD ,
A. Michael Lincoff, MD and
Gregg W. Stone, MD
* University of California Los Angeles and the Greater Los Angeles VA Medical Center, Los Angeles, California
Gaston Memorial Hospital, Gastonia, North Carolina
Columbia University Medical Center and The Cardiovascular Research Foundation, New York, New York
The Sarah Cannon Research Institute and The Centennial Heart Center, Nashville, Tennessee
|| New York University School of Medicine, New York, New York
¶ Lehigh Valley Hospital, Allentown, Pennsylvania
# Mayo Clinic, Rochester, Minnesota
** Duke University Medical Center, Durham, North Carolina
 Auckland City Hospital, Auckland, New Zealand
 Harvard University, Boston, Massachusetts
 Cleveland Clinic Foundation, Cleveland, Ohio
Manuscript received December 9, 2008;
revised manuscript received February 23, 2009,
accepted March 3, 2009.
* Reprint requests and correspondence: Dr. Ramin Ebrahimi, Greater Los Angeles VA Medical Center, Department of Medicine, Cardiology Section (111E), 11301 Wilshire Boulevard, Los Angeles, California 90073 (Email: ebrahimi{at}UCLA.edu).
Objectives: This study sought to evaluate the impact of upstream clopidogrel in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) requiring coronary artery bypass grafting (CABG) from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.
Background: Despite benefits of clopidogrel in patients with NSTE-ACS undergoing percutaneous coronary intervention, this agent is often not administered upstream (before angiography) as recommended by the American College of Cardiology/American Heart Association guidelines because of potential bleeding in the minority of patients who require CABG.
Methods: The ACUITY trial enrolled 13,819 patients with NSTE-ACS undergoing early invasive management. The timing of clopidogrel initiation was per investigator discretion. A 5-day washout period before CABG was recommended for patients having received clopidogrel.
Results: Of 13,819 patients enrolled, 1,539 (11.1%) underwent CABG before discharge. Clopidogrel-exposed patients had a longer median duration of hospitalization (12.0 days vs. 8.9 days, p < 0.0001), but fewer adverse composite ischemic events (death, myocardial infarction, or unplanned revascularization) at 30 days; 12.7% vs. 17.3%, p = 0.01), with nonsignificantly different rates of non–CABG-related major bleeding (3.4% vs. 3.2%, p = 0.87) and post-CABG major bleeding (50.3% vs. 50.9%, p = 0.83) compared with those patients not administered clopidogrel. By multivariable analysis, clopidogrel use before CABG was an independent predictor of reduced 30-day composite ischemia (odds ratio: 0.67, 95% confidence interval: 0.48 to 0.92, p = 0.001) but not of increased post-CABG major bleeding (odds ratio: 0.98, 95% confidence interval: 0.80 to 1.19, p = 0.80).
Conclusions: Clopidogrel administration before catheterization in patients with NSTE-ACS requiring CABG is associated with significantly fewer 30-day adverse ischemic events without significantly increasing major bleeding, compared to withholding clopidogrel until after angiography. These findings support the American College of Cardiology/American Heart Association guidelines for upstream clopidogrel administration in all NSTE-ACS patients, including those who subsequently undergo CABG. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158
[ClinicalTrials.gov]
).
Key Words: coronary artery bypass surgery clopidogrel acute coronary syndromes
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Abbreviations and Acronyms
| | ACC = American College of Cardiology | | ACS = acute coronary syndromes | | AHA = American Heart Association | | CABG = coronary artery bypass grafting | | CI = confidence interval | | CPK = creatine phosphokinase | | GP = glycoprotein | | MI = myocardial infarction | | NACE = net adverse clinical events | | NSTE = non–ST-segment elevation | | NSTEMI = non–ST-segment elevation myocardial infarction | | OR = odds ratio | | PCI = percutaneous coronary intervention | | STS = Society of Thoracic Surgeons | | UFH = unfractionated heparin | | ULN = upper limit of normal |
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