Conversations in Cardiology: Bridging Antithrombotic Therapy Between PCI & CABG

Question from my colleague,  Dr. Siddiqi:

"I have a 50yo WM, untreated DM and HTN, inferior stemi yesterday.  BMS placed in prox RCA and did great.  Peak troponin in 40s.  He has residual 3V CAD including ostial LAD, total mid LCx, and PDA disease with normal LVEF.

I can't send him home and bring him back as he has no insurance. I found a surgeon wiling to operate next week but he wanted to stop Plavix and bridge with IV heparin till then".

Our Questions for you::

1. Would you be comfortable with just ASA 325 and heparin post primary PCI?
2. What do your surgeons tell you about operating on Plavix and what should be require of them?
3. Is bridging with heparin logical for this issue?  why not GPB's til the day before surgery?

As always, no obligation to answer and all responses appreciated. 

Morton Kern
University of California, Irvine

Some questions do come to mind...

a.  How big a vessel was the stent put into?
b.  Was the stent placed with good evidence of apposition, i.e. step ups and down?

1. Would you be comfortable with just ASA 325 and heparin post primary PCI?  If above +, yes.
2. What do your surgeons tell you about operating on Plavix and what should be require of them?  Many in the country do, less so in the case of redo's, but here alas, not so much.
3. Is bridging with heparin logical for this issue?    Logical?  Dunno, but I probably would do so.  Why not GPB's until the day before surgery?  Another option, for sure, but costly.

Samuel M. Butman
Heart & Vascular Center of Northern Arizona

Heparin vs 2b3a:  2b3a (small molecule short acting, e.g. eptifibitide, tirofiban ) inhibitor makes more sense as a clopidogrel (P2Y12 inhibitor) substitute in that it provides platelet inhibition (far stronger than P2Y12) and is short acting. 

Aaron V. Kaplan
Dartmouth-Hitchcock Medical Center

Agree.  I guess another question is do you need anything if the patient is going right to surgery?  Also is the surgeon planning on grafting the RCA?  How big a vessel given it was a BMS?

Bonnie Weiner
Saint Vincent Hospital at Worcester Medical Center/Fallon Clinic

Our surgeons are variable in their willingness to operate on Plavix. However, they are fairly uniform in their distaste for operating in the first day after a full Plavix load. I agree with the caveats that have already been posted suggesting that individual risk is dependent on size and length of stent. Having said that, our strategy is to use eptifibatide for it's antiplatelet activity and short half life.

Frederick Welt
Brigham & Women's Hospital

This is a relatively common clinical dilemma. Here are some thoughts:

1. Would favor GPIIb/IIIa (or in future cangrelor) instead of heparin (unless the patient has severe renal failure), acknowledging that there is no hard data about this.
2. Our surgeons almost never operate in non-emergency cases on clopidogrel, which is probably reasonable given the increased risk of bleeding and need for re-exploration. Could use a platelet function test, such as Verify Now to potentially do CABG earlier than 5 days post stenting, depending on the return of platelet function.
3. Even with GPIIb/IIIa bridging stent thrombosis can occur after noncardiac surgery (usually during the first post-op day), however this is less of a risk post CABG, since the stented vessel will be bypassed at that time.

Manos Brilakis
VA North Texas Healthcare System

Keep the patient on clopidogrel. Our surgeons will routinely operate on patients who have received clopidogrel, either a load or maintenance therapy (the IPA isn’t that different), if the reasons are sound (as they are in this case). This is a better strategy than GPIIb/IIIa inhibitors because it will afford ischemic protection (i.e. against stent thrombosis) during the entire CABG procedure and in the immediate post-op period (the highest risk periods), whereas with GPIIb/IIIa inhibitors the drug must be stopped before, during and early post-surgery, and the patient will be unprotected. Bleeding will be moderately increased but can be minimized with good surgical technique, and two studies (CURE and ACUITY) have reported reduced ischemic MACE in ACS patients operated on shortly after clopidogrel compared to aspirin alone.

Gregg W. Stone
NewYork Presbyterian
Columbia University Medical Center
Cardiovascular Research Foundation

Agree with Gregg.  Would be concerned about heparin alone in this setting as it may actually stimulate platelet activation, which would not be completely overcome by aspirin alone.

Bob Applegate
Wake Forest Baptist Medical Center

I would guess that in this risk averse world, most surgeons continue to balk at operating on patients having received clopidogrel.  Not saying that is right or that there is robust data to support it but want to come back to the long term treatment of RCA.  If it is going to be grafted, there may be a downside to continuing anti platelet agents in terms of competitive flow and graft patency.  If it is not then I would continue if I could convince the surgeon.  2b/3a is most rational alternative but still issues preoperatively.

Bonnie Weiner

I think Dr. Stone's point is well made and perhaps the central issue is how to convince our surgical colleagues that the incremental risk of bleeding is outweighed by anti-ischemic properties. I would hazard that the vast majority of people on this e-mail chain would be in unity in their preference for continuation of Plavix. The problem we face is of course one of the anecdotal experience of a surgeon who has experienced a re-operation for bleeding in the middle of the night and attributes it rightly or wrongly to Plavix. This debate mirrors the one surrounding use of aspirin in CABG patients. My understanding is that it took evidence from the Antiplatelet Trialists Collaboration as well as from the VA cooperative studies to convince surgeons that despite higher bleeding risks the benefits from aspirin including SVG patency were worth it. Do people feel that the data we have from CURE and ACUITY are sufficient to convince our surgical colleagues at this point?

Frederick Welt

His biggest risk for MACE in the next 5 weeks is CABG, especially with a recent MI, a new stent, and uncontrolled DM. Also, his biggest risk for financial ruin is CABG. He has no short-term survival advantage with CABG (See FREEDOM figure or any other CABG study figure). If he is asymptomatic and has a normal LVEF, my strategy would be aspirin  with generic clopidogrel, metoprolol, simvastatin, and lisinopril; and risk factor control (does he smoke?). If the social worker can’t qualify him for Medicaid, he will probably be eligible for medical insurance January 1 when the Affordable Care Act kicks in and then elective CABG for a statistical survival advantage can be considered.

Eric Bates
University of Michigan

That’s a very reasonable approach, Eric.  However, it’s not fair to cite absence of short term benefit as a reason to withhold CABG.  Surgery always entails up-front risk.  But if his SYNTAX score (or whatever scoring system you prefer) indicates better long-term outcomes with CABG, he should get it.  His risk for ruin – financial and otherwise – is greatest if he gets a bunch of stents and doesn’t take DAPT.

Kirk Garratt
Lenox Hill Hospital

Have been reading all comments – very interesting dilemma and not an uncommon one (leaving the insurance issue aside). As usual, many different options proffered.

I think it might help if we could all see the angiogram – would that be possible? I am not quite sure why the immediate urgency in proceeding to CABG.

Malcolm Bell
Mayo Clinic

Thank you for all the insightful comments. To answer some of the questions. He recieved a 3.0x28mm BMS to prox RCA, posted with a 3.25 NC balloon. IVUS not performed; there was an adequate step-up and down. Opened collaterals to an occluded distal LCx via AV groove. BMS was chosen as non-IRA was shot first, knowing he may need bypass in future. I was not comfortable with POBA alone, due to length and appearance.  Numerous uncontrolled risk factors due to recent loss of medical insurance, common in our institution. Bypass was chosen as inpt due to residual severe prox to mid LAD lesion and as we couldn't bring him back. He had mild cp post PCI, but nothing similar to presentation.  Yes the surgeon will bypass the RCA as there is severe prox PDA disease. I wanted to go with Integrillin but wasn't sure if there was a time limit. MI was last Fri and bypass will be tomorrow, almost 5 days later. Pt at regional hospital with surgeon coming from parent institution. He was done well with ASA and heparin thus far.

Attached are some post-PCI stills (figure). As for the financial aspect, our hospital system has a charity program. For proactive pts, if they sign on for this, they can simply make payments indefinitely, with no affect on their credit. Vast majority of the acutes are unfunded so I routinely use this.

Nauman Siddiqi
Baylor Healthcare System

Our surgeons are happy to operate in the presence of plavix and do so all the time.  My experience is that patients operated on plavix have a greater transfusion  need and often have prolonged chest tube drainage.  I don't think that the "take  back" ratreater than in patients not on plavix.  I would encourage folks to move ahead with the needed surgery.

John Hirshfeld
University of Pennsylvania

Now that I've seen the stills, as long as I was ensured the patient would take  aspirin + clopidogrel (generic - 25 cents/day) for at least 6 months, I would  offer to the patient to treat the LAD with a long everolimus-eluting stent (with  IVUS), and leave the PDA alone for now and see how the patient does. This is a  low-moderate tertile SYNTAX score (depending on how you factor in the treated  RCA),  and the patient should do very well with best-in-class DES as long as he  can be adherent on DAPT. 

Gregg W. Stone

The LAD is diffusely diseased for a much longer segment than 32 mm. He isnt the  greatest candidate for either stent or CABG, but I agree I would try -- but I  might try medical therapy for those 6 months, get a stress test, then decide  whether he needs anything at that point. 

Lloyd Klein
Rush University Medical Center

Outcome: That was an impressive onslaught of responses. Glad to see there's no consensus among the experts. Thanks for helping me with that. I wanted to just fix the LAD like many recommended, but felt bad putting a very long 2.5 stent in the prox LAD in a young guy. He had bypass yesterday and is back on plavix, doing great. No issues with the heparin bridge

Nauman Siddiqi