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Invited Critique |

Is Timing Really Everything in Patients Receiving Antiplatelet Therapy?  Comment on “Cessation of Clopidogrel Before Major Abdominal Procedures”

Richard J. Bold, MD
Arch Surg. 2011;146(3):339. doi:10.1001/archsurg.2011.26b.
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A 65-year-old man with a nearly obstructing sigmoid colon cancer underwent cardiac catheterization 4 months ago and was receiving clopidogrel for his coronary stent (last dose on the day prior to my evaluation). Therefore, his circulating platelets had undergone irreversible inhibition, causing altered function. An emergent/urgent operation may be associated with increased bleeding that could be managed with either platelet or red blood cell transfusion; cessation of clopidogrel for 7 days before the procedure would be anticipated to allow replacement of the circulating platelet volume with functional platelets but perhaps put his coronary stent at risk for thrombosis. While this latter event may be catastrophic, the per-day risk is quite minimal; in the placebo arm of the PCI-CURE (Percutaneous Coronary Intervention–Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial1 of clopidogrel therapy in patients undergoing percutaneous coronary intervention with stent placement, 7.2% of the patients experienced myocardial infarction, urgent revascularization, or cardiovascular death during a year of follow-up. The question remains whether the bleeding that occurs in patients undergoing abdominal surgery during active antiplatelet therapy is manageable or whether it is associated with life-threatening complications. Chernoguz et al retrospectively reviewed the medical records of 104 patients who underwent a variety of abdominal operations and evaluated the outcomes stratified by the timing of clopidogrel cessation. The finding of an increased rate of postoperative bleeding requiring red blood cell transfusion in patients whose clopidogrel was withdrawn less than 7 days prior to surgery compared with those in whom it was stopped 7 or more days prior to surgery is not surprising and is consistent with many other studies. However, when controlling for other factors associated with operative morbidity or mortality (eg, American Society of Anesthesiologists classification, urgency of procedure), there was not a significant increase in major morbidity or overall mortality.

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