Clopidogrel use After Myocardial Revascularization: Prevalence, Predictors, and One-Year Survival Rate.
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INTRODUCTION: Antiplatelet therapy after coronary artery bypass graft (CABG) has been used. Little is known about the predictors and efficacy of clopidogrel in this scenario. OBJECTIVE: Identify predictors of clopidogrel following CABG. METHODS: We evaluated 5404 patients who underwent CABG between 2000 and 2009 at Duke University Medical Center. We excluded patients undergoing concomitant valve surgery, those who had postoperative bleeding or death before discharge. Postoperative clopidogrel was left to the discretion of the attending physician. Adjusted risk for 1-year mortality was compared between patients receiving and not receiving clopidogrel during hospitalization after undergoing CABG. RESULTS: At hospital discharge, 931 (17.2%) patients were receiving clopidogrel. Comparing patients not receiving clopidogrel at discharge, users had more comorbidities, including hyperlipidemia, hypertension, heart failure, peripheral arterial disease and cerebrovascular disease. Patients who received aspirin during hospitalization were less likely to receive clopidogrel at discharge (P≤0.0001). Clopidogrel was associated with similar 1-year mortality compared with those who did not use clopidogrel (4.4% vs. 4.5%, P=0.72). There was, however, an interaction between the use of cardiopulmonary bypass and clopidogrel, with lower 1-year mortality in patients undergoing off-pump CABG who received clopidogrel, but not those undergoing conventional CABG (2.6% vs 5.6%, P Interaction = 0.032). CONCLUSION: Clopidogrel was used in nearly one-fifth of patients after CABG. Its use was not associated with lower mortality after 1 year in general, but lower mortality rate in those undergoing off-pump CABG. Randomized clinical trials are needed to determine the benefit of routine use of clopidogrel in CABG.
Published Version (Please cite this version)
Prates, Paulo Roberto L, Judson B Williams, Rajendra H Mehta, Susanna R Stevens, Laine Thomas, Peter K Smith, L Kristin Newby, Renato AK Kalil, et al. (2016). Clopidogrel use After Myocardial Revascularization: Prevalence, Predictors, and One-Year Survival Rate. Braz J Cardiovasc Surg, 31(2). pp. 106–114. 10.5935/1678-9741.20160019 Retrieved from https://hdl.handle.net/10161/13607.
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"A North Carolina native, Dr. Williams believes in the mission of providing the best cardiovascular care that can be found in the world in his home state through WakeMed Health and Hospitals, Duke Health, and the HeartCare Plus collaborative. He feels fortunate to be part of the Heart Center because of the unique way he and his colleagues including anesthesiologists, physician assistants, surgical and heart center nurses, intensivists, and many others commit to individual patient care. Patients may expect from Dr. Williams a clear plan of care, compassion, and a patient-centered approach throughout their surgical consultation, procedures, and recovery."
Dr Mehta completed his Medical School in Mumbai, India; Residency at the Cleveland Clinic, Cleveland, Ohio, Cardiology Fellowship at University of Michigan, Ann Arbor, Michigan and Interventional Cardiology Fellowship at Duke University Medical Center, Durham, North Carolina. In addition, he has a Master’s degree from the School of Public Health-University of Michigan in Clinical Research Design and Biostatistics. He is board certified in Internal Medicine, General Cardiology and Interventional Cardiology. He was an Assistant Professor of Medicine with the Division of Cardiology at the University of Michigan in Ann Arbor, MI from 1998 to 2004.
Dr. Mehta is involved in clinical research and teaching at the Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC for past 14 years where he is a Consulting Professor. He has been the principal investigator for a recently completed Phase III clinical trial evaluating the efficacy of drug levosimendan in patients undergoing cardiac surgery. He has played a key role as a Clinical Events Committee (CEC) team member in the adjudication of clinical events as well as in the Phase I adjudication, as well as Phase II committee meetings in over 30 Phase III Clinical Trials. Dr. Mehta was the Chair of the CEC for recently completed large Phase III TRILOGY Trial and the Chair of the CEC for the large Phase III PORTICO Programs (PORTICO IDE PORTICO CAP and PORTICO Japan).
Dr. Mehta is a practicing cardiologist with a focus on Interventional Cardiology (coronary, peripheral, carotid and PFO closures) at the Sparrow Hospital and Allegiance Health System, Michigan. In his private practice, he is the site PI for site-based research studies including site PI for multicenter clinical research trials.
He is currently the Associate Editor of the American Heart Journal and a Section Editor for the Journal of Interventional Cardiology. He is also a reviewer for many peer-reviewed journals that include New England Journal of Medicine, JAMA, Archives of Internal Medicine, Circulation, Journal of the American College of Cardiology, American Journal of Cardiology, American Journal of Medicine, Lancet, British Medical Journal, British Heart Journal, European Heart Journal among others.
Dr. Mehta has authored over 250 articles in major peer-reviewed journals including the New England Journal of Medicine and JAMA on the topics related to various cardiovascular diseases. Specifically, he has been a senior author on multiple pioneering publications on the subject matter of TAVI. Besides research and clinical practice of cardiology, his other main passion has been teaching. As a result of his excellence in teaching, he was awarded the most coveted W Proctor Harvey, America’s Best Young Teacher Award by the American College of Cardiology.
As Deputy Director, Laine Thomas, PhD provides complementary leadership in strategy and development of the group and DCRI. She has an outstanding record of scientific and strategic collaboration, independent research, leadership and mentoring well known to her colleagues at the DCRI.
Thomas joined the DCRI in 2009. She serves as Associate Director for Biostatistics at DCRI and Associate Chair for Equity, Diversity and Inclusion within the Department of Biostatistics and Bioinformatics. She is a leader in developmental methods for observational and pragmatic studies. She has over 240 peer reviewed clinical and methodological publications arising from scientific collaboration in the therapeutic areas of cardiovascular disease, diabetes, uterine fibroids and SARS-CoV-2 virus. She led the statistical teams on the HERO COVID-19, ORBIT-AF I & II, ACTION-CMS, CHAMP-HF, and COMPARE-UF clinical registries and secondary analyses of the NAVIGATOR and ARISTOTLE clinical trials. She is the primary investigator of numerous methodological studies arising from these collaborations, addressing methods for causal inference in observational data, longitudinal treatment initiation, heterogeneous treatment effects and clinical trials augmented by external controls.
Dr. Smith is the Prinicpal Investigator for the Duke site in the Cardiothoracic Surgery Clinical Trials Network (CTSN) and in recent years has focused his research efforts in clinical research. The CTSN is an NHLBI sponsored network developed to promote clinical research in cardiac surgery, and is now entering its 7th year of funding with a commitment now for an additional 5 years. Dr. Smith is the national PI for a randomized clinical trial comparing CABG alone to CABG with mitral repair for moderate ischemic mitral regurgitation. This trial is nearing completion of enrollment, and he is now the PI of a clinical trial of FFR vs angiographically guided CABG expected to begin national enrollment in September of 2013. Duke has participated as a site in 3 additional CTSN trials, and is one of two sites awarded NHLBI funding as a Clinical Skills Education Core. This funding is designed to formally develop surgical clinical trialists and promote clinical research capacity within our specialty. The Duke site has thus far sponsored 6 CTSN scholars who have all received Masters degrees in clinical research, participated in CTSN protocols and other activities of the Network. Additionally, Dr. Smith has been awarded site funding from the Veteran’s Administration to begin VA cooperative clinical research trials at the Durham VA. Through all of these activities, an integration of clinical research, publications, and scholarship with the advancement of clinically effective Thoracic Surgery is the goal.
General Focus: Clinical investigation the process and treatment of acute and chronic coronary artery disease and systems issues for delivery of care to patients with these illnesses. Particular interests include management of patients with chest pain and unstable angina, evaluation of the use of biochemical markers other than CK-MB for diagnosis and risk stratification in these patients, issues related to coronary artery disease in women, and systems issues regarding optimizing the process of delivery of care to patients with acute and chronic coronary artery disease. Finally, I have a strong interest in defining the genetic contribution to development of coronary artery disease.
Key words: coronary artery disease acute myocardial infarction unstable angina chest pain women biochemical markers risk stratification genetics
John H. Alexander, MD, MHS is a cardiologist and Professor of Medicine in the Department of Medicine, Division of Cardiology at Duke University School of Medicine, as well as the Vice Chief, Clinical Research in the Division of Cardiology. He is the Director of Cardiovascular Research at the Duke Clinical Research Institute where he oversees a large group of clinical research faculty and a broad portfolio of cardiovascular clinical trials and observational clinical research programs. He is a member of the American Society of Clinical Investigation.
Dr. Alexander’s clinical interests are in acute and general cardiovascular disease, valvular heart disease, and echocardiology. His research is focused on the translation of novel therapeutic concepts into clinical data through clinical trials, specifically on the therapeutics of acute coronary syndromes, chronic coronary artery disease, and cardiac surgery and on novel methodological approaches to clinical trials. He was on the Executive Committee of the ARISTOTLE trial of apixaban in patients with atrial fibrillation and was the Principal Investigator of the APPRAISE-2 trial of apixaban in patients with acute coronary syndromes.
Dr. Alexander has published extensively and has served as the principal investigator of numerous multicenter clinical trials. He currently serves as the co-chair of the Clinical Trial Transformation Initiative (CTTI).
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