Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study.

Emma C Hansson,Shahab Nozohoor,Anders Jeppsson,Henrik Bjursten,Lena Jidéus,Torbjörn Ivert,Anders Holmgren,Rolf Svedjeholm,Mikael Barbu,Bengt Åberg,Mats Dreifaldt

doi:10.1093/eurheartj/ehv381

Abstract

AimsExcessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients.Methods and resultsAll acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012–13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72–120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53–1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72–120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04–2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56–0.92), P = 0.012].ConclusionThe incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.

Highlights

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12-receptor antagonist reduces the risk of thrombotic complications compared with treatment with only acetylsalicylic acid in patients with acute coronary syndrome (ACS).[1]
If a shorter discontinuation time of the platelet inhibitor would be safe from a bleeding perspective, it would reduce the risk of thrombotic complications during the waiting time, and save hospital resources
Preoperative treatment with low-molecular-weight heparin (LMWH) and fondaparinux was more common in the ticagrelor group

Summary

Introduction

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12-receptor antagonist reduces the risk of thrombotic complications compared with treatment with only acetylsalicylic acid in patients with acute coronary syndrome (ACS).[1]. More potent platelet inhibitors, ticagrelor or prasugrel, is used instead of clopidogrel,[2,3] but the risk of both spontaneous and surgical bleeding complications may increase with the new inhibitors.[3,4]. Major bleeding complications impair outcome after cardiac surgery.[5,6] Acute coronary syndrome patients on DAPT who need acute or urgent coronary artery bypass grafting (CABG) are at high risk of major bleeding.[6,7,8] Current revascularization guidelines recommend that clopidogrel and ticagrelor are discontinued 5 days before surgery and prasugrel 7 days before elective surgery,[9,10] but the patient’s condition may render this impossible. The risk of bleeding complications in relation to discontinuation time has not previously been investigated in real life in sufficiently large patient cohorts

Methods

Discussion

Conclusion