Similar observed CABG related bleeding complications in patients with and without clopidogrel loading doses / Complicaciones hemorrágicas asociadas a cirugía de revascularización miocárdica en pacientes con o sin dosis de carga de clopidogrel

Objective: Pretreatment with clopidogrel before percutaneous coronary intervention improves cardiovascular outcomes. However, some patients require elective coronary artery bypass graft (CABG) surgery instead, possibly increasing bleeding complications. We sought to assess the hemorrhagic complications and the length of hospital stay of stable patients receiving clopidogrel pretreatment that are referred for CABG. Methods: Between March and August 2007, 493 patients underwent diagnostic catheterization; 54 patients underwent elective CABG and were stratified according to clopidogrel loading dose (n = 20) or not (n = 34). Incidences of major hemorrhagic events and median post-surgical hospital stay were compared between groups. Results: TIMI Bleeding Index was not significantly different between the clopidogrel and no-clopidogrel groups (mean difference 0.46; 95% CI -0.89 to 1.82; p = 0.5). The incidence of major TIMI bleeding (70% vs. 73.5%; p > 0.9), peak hemoglobin loss > 5 g/dL (60% vs. 38.2%; p = 0.2), and blood transfusion > 4 units (20% vs. 26.5%; p = 0.7) in clopidogrel vs. no-clopidogrel group were not statistically different. Interestingly, the post-surgical length of stay was longer for the no-clopidogrel group (median of 5 vs. 7 days; p = 0.006). Conclusion: There was no significant evidence of increased bleeding or need for blood transfusion during CABG in patients pretreated with clopidogrel. The current practice of clopidogrel pretreatment before percutaneous coronary intervention does not significantly increase the risk of hemorrhagic complications in stable patients provided they can wait for at least 7 days before CABG. In a single center retrospective study, clopidogrel pretreatment was not found to be associated with increased bleeding or need for blood transfusion during coronary artery bypass graft surgery, suggesting that clopidogrel pretreatment before percutaneous coronary intervention does not significantly increase the risk of hemorrhagic complications in stable patients provided they can wait for 7 days before the surgery.

Objetivo: El pretratamiento con clopidogrel antes de la intervención precutánea coronaria, mejora los resultados cardiovasculares. Sin embargo, algunos pacientes que requieren cirugía programada de puente aortocoronario (CABG), posiblemente incrementan las complicaciones de sangrado. Nosotros buscamos valorar las complicaciones hemorrágicas y la duración de la estancia hospitalaria de los pacientes estables que reciben el pretratamiento de clopidogrel y que son enviados a CABG. Métodos: Entre los meses de marzo y agosto de 2007, 493 pacientes tuvieron diagnóstico de cateterización; 54 pacientes tuvieron una CABG programada y fueron estratificados con base en la dosis cargada de clopidogrel (n = 20) o no cargada (n = 34), y se compararon las incidencias de mayores eventos hemorrágicos y la media de estancia post operatoria entre ambos grupos. Resultados: El Indice de Sangrado TIMI no arrojó una diferencia significativa entre los grupos con clopidogrel y sin clopidogrel (la diferencia principal 0.46; 95% CI - 0.89 a 1.82; p = 0.5). La incidencia de mayor sangrado TIMI (70 % vs. 73.5%; p > 0.9) máxima pérdida de hemoglobina > 5 g/dL (60% vs. 38.2%; p = 0.2) y transfusión de sangre > 4 unidades (20% vs. 26.5%; p = 0.7) entre los grupos con clopidogrel y sin clopidogrel no fue estadísticamente diferente. Pero es interesante que el periodo de permanencia post operatoria fue más largo en el grupo que no fue tratado con clopidogrel (media de cinco vs. siete días: p = 0.006). Conclusión: No hay una evidencia significativa de incremento de sangrado o necesidad de transfusión sanguínea durante la CABG en pacientes pretratados con clopidogrel. La práctica actual del pretratamiento clopidogrel antes de la intervención precutánea coronaria no incrementa significativamente el riesgo de complicaciones hemorrágicas en pacientes estables siempre y cuando puedan esperar al menos siete días antes de la CABG. En un estudio simple de retrospectiva, no se encontró que el pretratamiento con clopidogrel se asociara con el incremento de sangrado o la necesidad de transfusión sanguínea durante la cirugía de puente aortocoronario, sugiriendo que el pretratamiento con clopidogrel antes de la intervención precutánea coronaria, no incrementa significativamente el riesgo de complicaciones hemorrágicas en pacientes estables siempre y cuando puedan esperar siete días antes de la cirugía.

Impaired myocardial perfusion score and inflammatory markers in patients undergoing primary angioplasty for acute myocardial infarction

BACKGROUND: Microcirculatory dysfunction during acute myocardial infarction is mediated by various mechanisms including inflammation, thrombus, or plaque embolization. We hypothesize that patients with acute myocardial infarction and admission Thrombolysis in Myocardial Infarction (TIMI) myocardial perfusion grade (TMP) < 2 had increased inflammatory status as measured by high sensitivity C-reactive protein (hs-CRP). METHODS: From January 2002 to December 2003, 166 patients (178 lesions) were referred for primary percutaneous coronary intervention. Patients were stratified based on pre-PCI TMP < 2 or TMP 2. Univariate and multivariate predictors of in-hospital and 30-day death were determined with logistic regression. RESULTS: Pre-PCI TMP < 2 was found in 66% vs 34% with TMP 2 (P < .001). Hs-CRP levels were high in both groups but not significantly different (37.9 +/- 6 vs 33.7 +/- 6 mg/L, P = .63). Patients with TMP < 2 had higher WBC (12.83 +/-4.55 x 10(-3) vs 10.83 +/- 3.00 x 10(-3), P = .04), lower ejection fraction (40 +/- 11% vs 46 +/- 12%, P < .001), and higher admission CK-MB levels (116 +/- 13 ng/mL vs 55 +/- 13 ng/mL, P = .006). Death occurred in 12% in the poorTMP group vs 1.8% in the good TMP group (P = .03). Advanced age, use of an intra-aortic balloon pump, and elevated admission WBC were independently associated with in-hospital and 30-day death. CONCLUSIONS: High hs-CRP levels were not associated with impaired myocardial perfusion score. Microcirculatory impairment may be related to an increased inflammatory process, independent from high hs-CRP levels.