CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Jeffrey S. Berger, MD, MS,
Carla B. Frye, PharmD,
Qing Harshaw, MD, PhD,
Fred H. Edwards, MD,
Steven R. Steinhubl, MD and
Richard C. Becker, MD*
* Duke University Medical Center, 2400 Pratt Street, Durham, North Carolina 27705 (Email: richard.becker{at}duke.edu).
We thank Drs. Patel and Mascarenhas for their insightful comments. Indeed, the management algorithm for patients with unstable angina/non–ST-segment elevation myocardial infarction does provide Class I options for platelet-directed pharmacotherapy on a background of aspirin, particularly among those in whom an early invasive strategy is selected according to validated risk scores (1). An ability to discriminate with a high degree of accuracy among patients likely to require surgical revascularization would undoubtedly facilitate a more targeted approach to pharmacotherapy, thereby avoiding delays, concomitant risks for recurring events (2), and perioperative hemorrhagic complications (3). Clearly the impact of treatment decisions is far-reaching, and might well become an even greater challenge with the introduction of increasingly robust platelet antagonists and their accompanying prolonged biological half-lives.
The preemptive identification of patients with surgical anatomy at the time of presentation is not a simple task, with existing models providing modest predictive accuracy and calibration (4,5). In addition, the ultimate decision to perform surgical over percutaneous revascularization is influenced by many factors—patient, family, physician, hospital, and healthcare system-specific considerations each apply. The risk of hemorrhage is also influenced by numerous variables not restricted to antithrombotic therapy (6).
The concomitant development and carefully designed investigation of short-acting or readily reversible antithrombotic agents, point-of-care measurement devices that permit a clear assessment of perioperative perturbation of hemostatic potential, and high-throughput platforms for advanced biomarkers to better predict patient-specific risk of bleeding (7) will collectively enrich and optimize the management of patients with non–ST-segment acute coronary syndromes who require coronary artery bypass grafting.
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References
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1. 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]2. Fox KAA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non–ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) trial Circulation 2004;110:1202-1208.[Abstract/Free Full Text] 3. Berger JS, Frye CB, Harshaw Q, et al. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis J Am Coll Cardiol 2008;52:1693-1701.[Abstract/Free Full Text] 4. Mehta RH, Chen AY, Pollack JCV, et al. Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non–ST-segment elevation acute coronary syndromes Am J Cardiol 2006;98:624-627.[CrossRef][Web of Science][Medline] 5. Chew DP, Mahaffey KW, White HD, et al. Coronary artery bypass surgery in patients with acute coronary syndromes is difficult to predict Am Heart J 2008;155:841-847.[CrossRef][Web of Science][Medline] 6. Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery Am Heart J 2008;156:886-892.[CrossRef][Web of Science][Medline] 7. Welsby IJ, Podgoreanu MV, Phillips-Bute B, et al. Genetic factors contribute to bleeding after cardiac surgery J Thromb Haemost 2005;3:1206-1212.[CrossRef][Web of Science][Medline]
Related Article
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Rethinking Loading Dose Clopidogrel in Light of Increased Bleeding Complications in Bypass Patients
- Sandeep Satish Patel and Daniel Mascarenhas
J. Am. Coll. Cardiol. 2009 54: 90.
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