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.

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.

MedLine Citation:	PMID: 19460609 Owner: NLM Status: MEDLINE
Abstract/OtherAbstract:	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).

Authors:	Ramin Ebrahimi; Cornelius Dyke; Roxana Mehran; Steven V Manoukian; Frederick Feit; David A Cox; Bernard J Gersh; E Magnus Ohman; Harvey D White; Jeffrey W Moses; James H Ware; A Michael Lincoff; Gregg W Stone
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Publication Detail:	Type: Comment; Comparative Study; Journal Article; Multicenter Study; Randomized Controlled Trial
Journal Detail:	Title: Journal of the American College of Cardiology Volume: 53 ISSN: 1558-3597 ISO Abbreviation: J. Am. Coll. Cardiol. Publication Date: 2009 May
Date Detail:	Created Date: 2009-05-22 Completed Date: 2009-06-09 Revised Date: -
Medline Journal Info:	Nlm Unique ID: 8301365 Medline TA: J Am Coll Cardiol Country: United States
Other Details:	Languages: eng Pagination: 1965-72 Citation Subset: AIM; IM
Affiliation:	University of California Los Angeles and the Greater Los Angeles VA Medical Center, Department of Medicine, Cardiology Section (111E), Los Angeles, California 90073, USA. ebrahimi@UCLA.edu
Data Bank Information
Bank Name/Acc. No.:	ClinicalTrials.gov/NCT00093158
Export Citation:	APA/MLA Format Download EndNote Download BibTex
MeSH Terms
Descriptor/Qualifier:	Acute Coronary Syndrome / diagnosis, drug therapy, surgery Adult Aged Aged, 80 and over Coronary Angiography Coronary Artery Bypass / methods Coronary Care Units Dose-Response Relationship, Drug Female Follow-Up Studies Heart Catheterization / methods* Humans Male Middle Aged Platelet Aggregation Inhibitors / administration & dosage* Preoperative Care / methods* Prospective Studies Ticlopidine / administration & dosage, analogs & derivatives* Time Factors Treatment Outcome Triage*
Chemical
Reg. No./Substance:	0/Platelet Aggregation Inhibitors; 55142-85-3/Ticlopidine; 90055-48-4/clopidogrel
Comments/Corrections
Comment On:	J Am Coll Cardiol. 2002 Oct 2;40(7):1366-74 [PMID: 12383588 ] J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157 [PMID: 17692738 ]
Comment In:	J Am Coll Cardiol. 2009 May 26;53(21):1973-4 [PMID: 19460610 ]

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