Tuesday, July 25, 2006

CRUSADE: Recommendations for ACS Patients on Clopidogrel Not Followed
By Julie McKeel

ACC/AHA guidelines recommend that non-ST-elevation ACS patients treated with acute clopidogrel stop the drug 5 days prior to surgery. However, new data from the CRUSADE registry show that the overwhelming majority of these patients do not have their surgery delayed for the recommended 5-day interval after stopping the drug.

[CRUSADE: Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines?]

Dr.

Although patients taken to surgery within 5 days of stopping clopidogrel did show an increased risk of bleeding, Mehta indicated that this was not as high as previously reported and did not translate into an increase in adverse events or mortality. "Physicians seem to be selecting patients appropriately for CABG, and surgeons do not appear to be frightened of operating on patients before the 5-day clopidogrel-free period is over," he told theheart.org.

According to Mehta, the lower-risk patients were more often taken to surgery within 5 days of stopping clopidogrel and surgeons have strategies to deal with the increased bleeding risk. Surgeons prefer to wait for the higher risk patients to become more stable and to minimize the risk of bleeding for these patients. "Our data suggest that sometimes practicing commonsense medicine rather than following guidelines is not necessarily associated with bad outcomes and can be more cost-effective," he added.

In this study, the authors note that in the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial, the risk of death, heart attack or stroke was reduced by 20% for ACS patients who received clopidogrel. However, the guidelines recommend that clopidogrel be discontinued at least 5 days before CABG surgery due to the increased risk of bleeding.

Mehta's team analyzed data from 2858 ACS patients undergoing CABG at 264 U.S. hospitals participating in the CRUSADE initiative to determine whether this guideline was being followed in clinical practice. Within 24 hours of admission, 852 ACS patients (or 30%) received clopidogrel. Of these patients, 87% underwent surgery within 5 days of clopidogrel treatment and had a significant increase in blood transfusions. However, the death and heart attack rate did not increase for these patients, and they had significantly shorter hospital stays than those patients waiting for more than 5 days.

For those patients where surgery was delayed for more than 5 days, the transfusion rate did not increase.

This study provides insight into patterns of clopidogrel use and surgery outcomes for ACS patients. The authors point out that while it may be suspected that those patients undergoing CABG before clopidogrel had worn off completely would be at higher risk, the data show that this was not the case, and that it appeared that that surgery was performed sooner than is recommended after the discontinuation of clopidogrel in the vast majority of patients.

While those patients who underwent surgery within 5 days of clopidogrel use experienced an increase in blood transfusions, this increase was smaller than those seen in previous case series, which the authors say may reflect a more stable estimate of risks based on a much larger case sample or may be due to increased experience with management of patients treated with clopidogrel.

The CURE trial results suggested benefits of very early use of clopidogrel for this patient population. According to the authors of this latest study, "The benefits of delaying CABG surgery for more than 5 days after the administration of clopidogrel must be weighed against the potential risk of events while waiting as well as the economic consequences of extended hospital length of stay."

DCRI authors for this study include Drs. Matthew Roe, Magnus Ohman, and Eric Peterson.