Early on-pump coronary artery bypass grafting after clinically stable non-ST-segment elevation myocardial infarction with recent clopidogrel exposure versus elective surgery: a propensity score-matched cohort study

Optimal timing of coronary artery bypass grafting (CABG) after non-ST-segment elevation myocardial infarction (NSTEMI) and perioperative management of recent clopidogrel exposure remain related but distinct clinical issues. We compared a selected, clinically stable NSTEMI early-CABG pathway with recent clopidogrel exposure versus elective no-clopidogrel CABG. We analysed 444 eligible isolated on-pump CABG patients from 2015 to 2017: 160 clinically stable NSTEMI patients and 284 elective patients without documented pre-admission clopidogrel exposure; elective patients with documented aspirin plus clopidogrel were excluded. The intended 24-30-hour interval was protocol-defined and was not based on measured last-dose-to-incision timing or platelet function recovery. Propensity score matching incorporated baseline risk and coronary anatomical complexity. Median admission-to-surgery time among NSTEMI patients was 2 days, and 93.1% underwent CABG within 3 days. In 152 matched pairs, 1-year mortality was 7.2% in the NSTEMI/clopidogrel pathway group and 3.3% in the elective/no-clopidogrel group (risk difference + 3.9 percentage points; 95% confidence interval − 1.3 to + 9.7). The primary bleeding outcome occurred in 25.7% versus 19.7% (risk difference + 5.9 percentage points; 95% confidence interval − 3.4 to + 15.2). Re-exploration for bleeding was 5.9% versus 5.3%. In this selected retrospective cohort, statistically significant differences in 1-year mortality or the primary bleeding outcome were not observed between clinically stable NSTEMI patients managed within an early on-pump CABG pathway with recent clopidogrel exposure and elective no-clopidogrel CABG patients. However, the retrospective design and limited number of events preclude definitive safety conclusions. These findings should be interpreted as a selected historical institutional pathway experience rather than as evidence supporting shortened clopidogrel discontinuation before CABG.