RISK OF BLEEDING COMPLICATIONS IN PATIENTS TREATED WITH TICAGRELOR UNDERGOING URGENT CORONARY ARTERY BYPASS GRAFTING SURGERY: A SINGLE CENTER EXPERIENCE

Abstract

Canadian guidelines recommend using ticagrelor over clopidogrel in patients with acute coronary syndrome (ACS). Because of its more potent antiplatelet effect, there are some concerns regarding the risk of bleeding complications in patients undergoing urgent coronary artery bypass grafting (CABG) surgery who received ticagrelor prior to surgery. We included all consecutive ACS patients treated with a parenteral anticoagulant who received an ADP receptor inhibitor (ADPri) within 7 days of CABG. Bleeding events, blood loss and blood transfusions were compared between patients who received ticagrelor and those who received clopidogrel. Major bleeding was defined according to the Bleeding Academic Research Consortium. Between February 2012 and February 2014, 383 patients (55 ticagrelor, 328 clopidogrel) met the inclusion criteria. Overall, there was no difference in bleeding parameters between ticagrelor and clopidogrel patients (Table). When the ADPri was stopped <48h, ticagrelor patients had a higher mean intra-operative blood loss (850cc vs 550cc;p=0.02), higher post-operative chest tube drainage at 4h (405cc vs 310cc;p=0.02), were more likely to have chest tube drainage >2L (11.5% vs 1.3%;p=0.03) and to receive blood products (platelets: 73% vs 50%,p=0.02; plasma: 50% vs 26%,p=0.02; red blood cells: 69% vs 40%,p=0.01). In patients with ADPri stopped >48h, there was no significant differences in bleeding parameters except for chest tube drainage at 4h (ticagrelor 240cc, clopidogrel 345cc; p=0.03). In this subgroup, there was a trend for less major bleeding in ticagrelor patients (0% vs 8%; p=0.1). Major bleeding was significantly less frequent when the ADPri was stopped at least 48h before surgery (ticagrelor: 23% vs 0%, p=0.01; clopidogrel: 16% vs 8%,p=0.03)(Figure). In this small study, ticagrelor, when compared to clopidogrel, was not associated with an increased risk of major bleeding in ACS patients undergoing CABG within 7 days of stopping the ADPri. In patients undergoing CABG within 48h of stopping the ADPri, there was a significant increase in the risk of bleeding in patients treated with ticagrelor. However, when ticagrelor is stopped at least 48h before surgery, the risk of bleeding is comparable to clopidogrel. Delaying CABG >48h after the last ADPri dose significantly reduces bleeding risk whether patients are pre-treated with ticagrelor or clopidogrel. Larger studies are needed to investigate the ideal timing of surgery in patients treated with ticagrelor. Postponing surgery for 48h whenever possible seems justified. Pre-treatment with ticagrelor should probably be withheld in patients with a high likelihood of urgent (<48h) CABG.View Large Image Figure ViewerDownload (PPT)