So clopidogrel within 5 days of CABG obviously causes issues with bleeding. My question for any smart cardiologists is are there any particular features of an NSTEMI presentation that would make the patient high risk for 3VD or LMS that would make you want to hold clopidogrel in the first instance (on the basis that they are more likely to need CABG)? For example, if you saw the diffuse ST depression and STE in avR which is associated with LM occlusion?
Clopidogrel and CABG
- Thread starter Radetzky
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Practice patterns obviously vary but P2Y12 inhibitors are a crucial part of NSTEMI care and predicting who will end up needing CABG has proven unreliable, at least in any systematic way. Furthermore, in the ACUITY trial, investigators found that NSTEMI patients who received clopidogel and later underwent CABG (>5 days) had improved outcomes compared to those who did not receive clopidogrel without an increase in bleeding complications. With that said, if you KNOW they will need CABG (i.e. if they come in with known 3V-disease without surgical contraindications) then obviously that may change things.
Cool, very helpful, thanks.
If the patient is going to the cathlab sooner than later, you can hold off plavix. Remember that when they define the anatomy the interventionalist can always give Prasugrel on the table prior to stenting.
High risk features include elevation in AVR, diffuse ST elevation (multiple territories), TIMI score, size of the enzyme....none of them is specific otherwise a pretty ugly ST changes in multiple coronary territories.
In my institution we try to encourage the residents and ER to not rush to give 2B3A inhibitors. STEMI they can give the meds and we deal with consequences later.
High risk features include elevation in AVR, diffuse ST elevation (multiple territories), TIMI score, size of the enzyme....none of them is specific otherwise a pretty ugly ST changes in multiple coronary territories.
In my institution we try to encourage the residents and ER to not rush to give 2B3A inhibitors. STEMI they can give the meds and we deal with consequences later.
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Agree with both of these. Technically we do have some data on our side about the safety of giving clopidogrel prior to CABG in regards to bleeding risk though if you talk to your surgeons they'll likely say otherwise and mention anecdotally that they see much more bleeding operating with those meds on board. For what it's worth I seem to notice more issues with bleeding while doing devices (pacers/ICDs) on patients taking DAPT as opposed to those therapeutic on warfarin or a NOAC....
Guidelines do suggest the use of upstream DAPT in ACS though local patterns may dictate what you do and where I did my general training we tended to hold off on giving it in the majority of cases (some exceptions mostly dealing with clinical status and known prior disease) until the anatomy was seen in cath lab.
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Agree w/ the above.
The issue of upstream p2y12 inhibitors for NSTEMI has been a big headache for me throughout fellowship between dealing with overzealous residents who rightfully quote the guidelines and pissed off attendings who have to babysit patients with surgical disease after a plavix load. I'm glad you bring this up because I think this is an important issue that needs more guidance or clarification, especially for the front line guys, so here are my 2 cents.
With the exception of diffuse ST depressions and/or AVR elevation on EKG or multiple wall motion abnormalities on echo, there are no features that reliably predict the presence of multi vessel or LM disease. A poorly controlled diabetic or pt with multiple uncontrolled risk factors may heighten my suspicion.
w/ regards to timing of CABG after clopidogrel load, some surgeons do not mind taking a patient to the OR after 1 load, but others will. Find out your surgeon's preference before blindly committing to an upstream loading strategy.
IMO, unless you foresee a delay to cath >24-48 hrs, i don't think you risk too much from holding it. Another alternative strategy which is endorsed by the NSTEMI guidelines, but not well recognized is the use of a gp2b3a inhibitor i.e eptifibatide or tirofiban as your second anti platelet agent. Cangrelor can also play a role here, although not specifically studied.
All in all, if your surgeon will not operate after one plavix load, I would discourage upstream plavix until coronary anatomy is defined. Hope this helps
The issue of upstream p2y12 inhibitors for NSTEMI has been a big headache for me throughout fellowship between dealing with overzealous residents who rightfully quote the guidelines and pissed off attendings who have to babysit patients with surgical disease after a plavix load. I'm glad you bring this up because I think this is an important issue that needs more guidance or clarification, especially for the front line guys, so here are my 2 cents.
With the exception of diffuse ST depressions and/or AVR elevation on EKG or multiple wall motion abnormalities on echo, there are no features that reliably predict the presence of multi vessel or LM disease. A poorly controlled diabetic or pt with multiple uncontrolled risk factors may heighten my suspicion.
w/ regards to timing of CABG after clopidogrel load, some surgeons do not mind taking a patient to the OR after 1 load, but others will. Find out your surgeon's preference before blindly committing to an upstream loading strategy.
IMO, unless you foresee a delay to cath >24-48 hrs, i don't think you risk too much from holding it. Another alternative strategy which is endorsed by the NSTEMI guidelines, but not well recognized is the use of a gp2b3a inhibitor i.e eptifibatide or tirofiban as your second anti platelet agent. Cangrelor can also play a role here, although not specifically studied.
All in all, if your surgeon will not operate after one plavix load, I would discourage upstream plavix until coronary anatomy is defined. Hope this helps
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