Patients should not take the antiplatelet drug clopidogrel for five days before undergoing robotic coronary artery bypass graft (CABG) procedures, according to researchers at the University of Arizona. 
In 2011, the American Heart Association issued a recommendation to hold clopidogrel for five days before traditional CABG, but the organization had not made a similar statement for the robotic procedure. “This study provides food for thought,” said Sophia Vainrub, PharmD, a clinical pharmacist at the University of Arizona, in Tucson, “to justify applying the practice of holding clopidogrel for five days before CABG to robotic CABG procedures as well.” 
In a retrospective study of 136 patients who underwent robotic CABG, 29% received clopidogrel five days before surgery. Bleeding occurred in a significantly higher percentage of patients who received clopidogrel than patients who did not (26% vs. 8%, respectively; P=0.011). Likewise, patients in the clopidogrel group had a higher median chest tube output during the 24-hour period after surgery than did patients who did not receive the drug (900 vs. 735 mL, respectively; P=0.002). Although it does not involve a sternotomy, robotic CABG still is associated with bleeding, Dr. To said, particularly at the targeted vessel and incision sites.
“These data serve as a good starting point of investigation into the clinical ramifications of higher intraoperative blood loss and higher chest tube output in the first 24 hours following robotic CABG,” Dr. Vainrub told Pharmacy Practice News. “Since those parameters were statistically significantly different in our small patient sample, when applied to a larger patient population, it is possible that they may prove clinically significant. However, a larger study would be needed to evaluate this appropriately.” 
The choice to hold clopidogrel should be tailored to an individual patient’s needs, Dr. To said. It’s standard practice to hold clopidogrel before traditional CABG, but if a patient has a history of myocardial infarction and is at high risk for reinfarction, clinicians “don’t want to [incur] any risk [they] don’t have to” and they may want the patient to continue to take clopidogrel. The higher odds of bleeding may be preferable compared with increased chances of reinfarction.
“I think the result is interesting, but I don’t think it is surprising,” said Long To, PharmD, a clinical pharmacist at Henry Ford Hospital, in Detroit, who was not involved with this research. It will provide a good reference for clinicians, who might have questions about the increasingly popular robotic procedure, Dr. To said.
 Drs. To and Vainrub reported no relevant financial conflicts of interest. The results were first presented at the 2013 American College of Clinical Pharmacy meeting (abstract 91).