CORRESPONDENCE: LETTER TO THE EDITOR
Rethinking Loading Dose Clopidogrel in Light of Increased Bleeding Complications in Bypass Patients
Sandeep Satish Patel, MD and
Daniel Mascarenhas, MD*
* Drexel University Cardiology, 175 South 21st Street, Easton, Pennsylvania 18042 (Email: danmasc{at}rcn.com).
The recent paper by Berger et al. (1) brings to light an important point that we think affects a majority of cardiologists and cardiac surgeons alike. The use of clopidogrel is now widespread, and the American College of Cardiology/American Heart Association (ACC/AHA) guidelines (2) highlight the indications for its use. However, more often we anecdotally observe indiscriminate use of loading dose clopidogrel, especially by emergency room physicians and internists, leading to delays in emergent or urgent coronary artery bypass grafting (CABG) and/or increased bleeding complications.
The guidelines (2) list a Class 1 indication for choosing between clopidogrel or a glycoprotein IIb/IIIa inhibitor when an early invasive strategy is chosen in patients with unstable angina/non–ST-segment elevation myocardial infarction. The guidelines do not specify the timing of its use, and herein is where the problem lies. It is reasonable to deduce from the current published data that (3) clopidogrel could be given during catheterization after coronary anatomy is determined, especially in patients going to catheterization within 6 h and particularly in those patients that might need bypass. These patients might be better served with more aggressive use of other anticoagulants and glycoprotein IIb/IIIa inhibitors that are easily reversible, thereby circumventing having to wait 5 days after loading dose clopidogrel.
A large study by Mehta et al. (4) showed that almost one-third of patients needed CABG within 5 days of clopidogrel use. These had increased need for red cell transfusions.
Studies are lacking on how to discriminate who might need CABG. Sadanandan et al. (5) did show that a validated risk scoring system might be applied to discriminate patients who might have a higher chance of needing CABG and thus holding clopidogrel use until coronary anatomy is defined.
The authors feel that more widespread use of risk scoring systems might improve patient outcomes for CABG and better discriminate the need for loading dose clopidogrel, especially because effective and quickly reversible anticoagulant agents have been safely used and widely studied (e.g., glycoprotein IIb/IIIa inhibitors).
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1. Berger JS, Frye CB, Harshaw Q, et al. Impact of clopidogrel use in patients with acute coronary syndromes requiring coronary bypass surgery: a multicenter analysis J Am Coll Cardiol 2008;51:1693-1701.2. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) J Am Coll Cardiol 2007;50:e1-e157.[Free Full Text] 3. Casterella PJ, Tcheng JE. Review of the ACC, AHA, and Society for Cardiovascular Interventions guidelines for adjunctive pharmacologic therapy during percutaneous interventions: practical implications, new clinical data, and recommended guideline revisions Am Heart J 2008;155:781-790.[CrossRef][Web of Science][Medline] 4. Mehta RH, Roe MT, Mulgund J, et al. Acute clopidogrel use and outcomes in patients treated with non–ST-segment elevation acute coronary syndromes undergoing CABG J Am Coll Cardiol 2006;48:281-286.[Abstract/Free Full Text] 5. Sadanandan S, Cannon CP, Gibson CM, Murphy SA, DiBattiste PM, Braunwald E, TIMI Study Group A risk score to estimate the likelihood of CABG during the index hospitalization among patients with UA and NSTEMI J Am Coll Cardiol 2004;44:799-803.[Abstract/Free Full Text]
Related Article
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Reply
- Jeffrey S. Berger, Carla B. Frye, Qing Harshaw, Fred H. Edwards, Steven R. Steinhubl, and Richard C. Becker
J. Am. Coll. Cardiol. 2009 54: 90-91.
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