Management and Outcomes of Patients on Preoperative Plavix (Clopidogrel) Undergoing General Thoracic Surgery

Abstract

Objectives Plavix (clopidogrel) is a potent antiplatelet agent used to prevent thrombosis in a variety of clinical settings. The perioperative management of thoracic surgery patients who are on clopidogrel at the time of surgery is not well defined. We conducted this review to examine the perioperative management and outcomes of patients undergoing general thoracic surgical procedures.

Methods From January 2005 to January 2010, 165 patients on clopidogrel underwent 182 operative procedures. Three management strategies were identified: Group I: clopidogrel continued through surgery (n = 17), Group II: clopidogrel discontinued with a bridging agent (n = 44) and Group III clopidogrel discontinued without a bridging agent (n = 121). Propensity score matched cohorts (17 clopidogrel continued; 34 clopidogrel discontinued) were constructed based on age, clopidogrel indication, American Society of Anesthesiology status, and procedure and used to compare the impact of clopidogrel management on postoperative bleeding and cardiovascular morbidity.

Results Unmatched analysis revealed a significantly higher rate of transfusion in the group of patients who continued on clopidogrel throughout the perioperative period, compared with patients who had clopidogrel discontinued. Although there were more cardiovascular events in Groups II and III, there were no significant differences between groups in postoperative mortality, myocardial infarction, stroke, or reoperation for bleeding. In propensity matched patients only the rate of postoperative transfusions was significantly higher in patients continued on clopidogrel compared with patients whose clopidogrel was discontinued (35.3 vs. 2.9%), p < 0.004.

Conclusions In selected patients, some thoracic surgical procedures can be performed safely on clopidogrel but are associated with higher rates of postoperative transfusion.

Keywords

antiplatelet therapy - thoracic surgery - clopidogrel

• References

• 1 Grines CL, Bonow RO, Casey Jr DE , et al; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Dent Assoc 2007; 138 (5) 652-655
• 2 Eisenstein EL, Anstrom KJ, Kong DF , et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007; 297 (2) 159-168
• 3 Iakovou I, Schmidt T, Bonizzoni E , et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293 (17) 2126-2130
• 4 Jeremias A, Sylvia B, Bridges J , et al. Stent thrombosis after successful sirolimus-eluting stent implantation. Circulation 2004; 109 (16) 1930-1932
• 5 Park DW, Park SW, Park KH , et al. Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. Am J Cardiol 2006; 98 (3) 352-356
• 6 Angiolillo DJ, Firstenberg MS, Price MJ , et al; BRIDGE Investigators. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA 2012; 307 (3) 265-274
• 7 Coca-Perraillon M. Matching with Propensity Scores to Reduce Bias in Observational Studies. Proceedings of the NorthEast SAS Users Group Conference (NESUG). Philadelphia 2006.
• 8 Cutlip DE, Baim DS, Ho KK , et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation 2001; 103 (15) 1967-1971
• 9 Cerfolio RJ, Minnich DJ, Bryant AS. General thoracic surgery is safe in patients taking clopidogrel (Plavix). J Thorac Cardiovasc Surg 2010; 140 (5) 970-976
• 10 Chu MW, Wilson SR, Novick RJ, Stitt LW, Quantz MA. Does clopidogrel increase blood loss following coronary artery bypass surgery?. Ann Thorac Surg 2004; 78 (5) 1536-1541
• 11 Yende S, Wunderink RG. Effect of clopidogrel on bleeding after coronary artery bypass surgery. Crit Care Med 2001; 29 (12) 2271-2275
• 12 Gurbel PA, Bliden KP, Hiatt BL, O'Connor CM. Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation 2003; 107 (23) 2908-2913