Should clopidogrel be discontinued before coronary artery bypass grafting for patients with acute coronary syndrome? A systematic review and meta-analysis

Objective: Patients presenting with acute coronary syndrome (ACS) are treated with dual antiplatelet agents, including aspirin and clopidogrel, to prevent mortality and recurrent ischemia. However, those who require coronary artery bypass grafting (CABG) could have increased postoperative bleeding and bleeding-related adverse outcomes. The current guidelines on clinical management differ significantly. The present meta-analysis examined the evidence for clopidogrel in the treatment of patients presenting with ACS requiring CABG, with a focus on the timing of medication cessation before surgery. Methods: A systematic review of 9 electronic databases was performed to identify all relevant studies with comparable outcomes for patients with ACS treated with clopidogrel before CABG. The endpoints included reoperation, major bleeding, mortality, and a composite endpoint of mortality and recurrent myocardial infarction. Results: Five relevant studies were identified according to the predefined selection criteria. Patients who had received clopidogrel had a significantly lower incidence of composite endpoints than those who had not. However, patients who underwent CABG < 5 days after the last dose of clopidogrel had a significantly greater incidence of reoperation, major bleeding, and combined adverse outcomes than those who had had a washout period > 5 days. Conclusions: The results from the present meta-analysis suggest that patients who present with ACS should be treated with dual antiplatelet therapy, including clopidogrel. However, for patients subsequently referred for CABG, a minimum washout period of 5 days should be observed to minimize perioperative bleeding and bleeding-related complications, unless emergency indications exist. These results differ from those of previous studies and guidelines.