January 26, 2023

Clopidogrel and CABG in ACS

The genuine article discussion and commentary based on articles from jack hello i’m tony to marry the editor of jack here with another issue of the genuine article and today we’re going to try to answer the question of whether or not we should give our acs patients clopidogrel prior to catheterization knowing full well some of them may go to cabbage surgery and

In fact whether or not we should delay cabbage surgery in those patients who come in with acs already on clopidogrel and to answer that for us from the acuity trial is dr. ramin ebrahimi and dr. ebrahimi is associate professor of medicine at the greater los angeles va medical center and at ucla so rameen tell us a little bit about the analysis you did from the

Acuity trial this was a sub analysis of the acuity trial that looked at moderate to high risk patient who were admitted for acute coronary syndrome and of the over 13,800 about 1500 patient 1539 patient ended up in bypass surgery in this trial the copa de girl use was left at the discretion of the physicians and it allowed us to look at the practice of given or not

Giving cooper a girl before cabbage a wonderful database so as i recall you had about 700 patients who receive clopidogrel prior to cabbage and about an equal number who did not that’s correct almost fifty fifty percent fifty percent got care cool particular for cabbage and fifty percent did not and what endpoints were you looking at we looked at schema can point a

Standard schema can points out debt myocardial infarction and need for urgent revascularization as well as a bleeding endpoint which was a primary endpoint from acuity so it truly allowed us to look at bleeding problems with these patients good and what did you find that the patients who went to cabbage having received close we’ll have more ischemic events or more

Bleeding interestingly enough what they found is given cool pita grill actually is an independent predictor of a lower scheming outcome they had significantly lower scheming outcome most of which was decreasing myocardial infarction and by the same token when we looked at the bleeding outcomes there was no significant increase in non cabbage major bleeding or post

Cabbage major bleeding now i assume most of the patients who got clopidogrel were helped 45 days is that correct that was our recommendation based on accha guidelines interestingly enough about sixty eight percent of these patients ended up going to going to cabbage prior to the recommended five days and this deviation from the guidelines is not new the previous

Data set published based on doctor made us the data from crusade which was published in 2016 jack showed the same thing that almost eighty to ninety percent of these patients do not wait five days to go to cabbage so this is really unexpected at least to me in my practice the patients who receive clopidogrel prior to cabbage surgery had less ischemic events and no

Additional bleeding events am i correct about that that’s correct no no increase now one of the limitation was that the intra op leading complications were not specifically looked at but again that is not uncommon in some of the previous trials that have done these analysis well with those data have you changed your practice now do you give all patients with acs

Clopidogrel prior to angiography or are you delaying surgery in those patients i think the data strengthens the evidence for usage of dual or antiplatelet therapy in patients with acute coronary syndrome and it certainly gives us a little bit more confidence in terms of using an agent such as coal pettigrew without worrying about the bleeding complications well i

Guess we could say that the ideal course of action is to give clopidogrel and then if the patient needs surgery to wait five days and by doing this will reduce ischemic events and in fact have no additional bleeding risk but if we have to operate earlier it’s very encouraging that that the data seem to support that clopidogrel is not an absolute contraindication

To surgery prior to five days for the genuine article i’m telling you the merrier you

Transcribed from video
Inside JACC | Clopidogrel and CABG in ACS By American College of Cardiology Video Archive 2