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Invited Critique
June 2013

Balancing Thrombotic and Bleeding Risks Related to Antiplatelet Therapy in Coronary Bypass SurgeryComment on “Protective Effects of Tranexamic Acid on Clopidogrel Before Coronary Artery Bypass Grafting”

JAMA Surg. 2013;148(6):548. doi:10.1001/jamasurg.2013.1571

Combined antiplatelet therapy with aspirin and clopidogrel (or an alternative P2Y12 receptor blocker) is standard of care in patients with acute coronary syndromes1-3 and after percutaneous coronary intervention4-6 because it reduces myocardial infarction and death related to coronary thrombosis. Such patients commonly present for urgent and emergent CABG, where dual antiplatelet therapy is associated with a 2-fold increase in risk of blood transfusion, 5-fold increase in risk of reoperation, and 50% increase in risk of wound infection.7,8 Balancing these thrombotic and bleeding risks is critical when deciding to continue or withdraw antiplatelet agents in patients who require surgery. In the absence of randomized clinical trials that compare both strategies head to head, clinicians are forced to rely on evidence from observational studies and expert opinion to guide therapy. The current consensus recommendation from multiple expert panels is to continue aspirin therapy but withhold clopidogrel for 5 days prior to CABG in the vast majority of cases.9-12

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