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Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.

Publication ,  Journal Article
Ebrahimi, R; Dyke, C; Mehran, R; Manoukian, SV; Feit, F; Cox, DA; Gersh, BJ; Ohman, EM; White, HD; Moses, JW; Ware, JH; Lincoff, AM; Stone, GW
Published in: J Am Coll Cardiol
May 26, 2009

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).

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Published In

J Am Coll Cardiol

DOI

EISSN

1558-3597

Publication Date

May 26, 2009

Volume

53

Issue

21

Start / End Page

1965 / 1972

Location

United States

Related Subject Headings

  • Triage
  • Treatment Outcome
  • Time Factors
  • Ticlopidine
  • Prospective Studies
  • Preoperative Care
  • Platelet Aggregation Inhibitors
  • Middle Aged
  • Male
  • Humans
 

Citation

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Ebrahimi, R., Dyke, C., Mehran, R., Manoukian, S. V., Feit, F., Cox, D. A., … Stone, G. W. (2009). Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol, 53(21), 1965–1972. https://doi.org/10.1016/j.jacc.2009.03.006
Ebrahimi, Ramin, Cornelius Dyke, Roxana Mehran, Steven V. Manoukian, Frederick Feit, David A. Cox, Bernard J. Gersh, et al. “Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.J Am Coll Cardiol 53, no. 21 (May 26, 2009): 1965–72. https://doi.org/10.1016/j.jacc.2009.03.006.
Ebrahimi R, Dyke C, Mehran R, Manoukian SV, Feit F, Cox DA, Gersh BJ, Ohman EM, White HD, Moses JW, Ware JH, Lincoff AM, Stone GW. Outcomes following pre-operative clopidogrel administration in patients with acute coronary syndromes undergoing coronary artery bypass surgery: the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol. 2009 May 26;53(21):1965–1972.
Journal cover image

Published In

J Am Coll Cardiol

DOI

EISSN

1558-3597

Publication Date

May 26, 2009

Volume

53

Issue

21

Start / End Page

1965 / 1972

Location

United States

Related Subject Headings

  • Triage
  • Treatment Outcome
  • Time Factors
  • Ticlopidine
  • Prospective Studies
  • Preoperative Care
  • Platelet Aggregation Inhibitors
  • Middle Aged
  • Male
  • Humans