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Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a
Emma C Hansson1, Lena Jidéus2, Bengt Åberg3
1Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden.
Insights
Shortening dual antiplatelet therapy discontinuation before coronary artery bypass grafting (CABG) did not increase bleeding risk with ticagrelor but did with clopidogrel. Ticagrelor use was associated with lower overall major bleeding complications after CABG.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Excessive bleeding is a significant complication following coronary artery bypass grafting (CABG).
- Current guidelines recommend discontinuing clopidogrel and ticagrelor 5 days before elective CABG, balancing bleeding and thrombotic risks.
- Shorter discontinuation periods may reduce thrombotic events and healthcare costs but could increase bleeding complications.
Purpose of the Study:
- To investigate if shorter discontinuation times for ticagrelor and clopidogrel before CABG increase major bleeding complications.
- To compare the incidence of major bleeding complications between ticagrelor- and clopidogrel-treated patients undergoing CABG.
Main Methods:
- Retrospective observational study of 2244 acute coronary syndrome patients in Sweden on dual antiplatelet therapy (aspirin plus ticagrelor or clopidogrel) undergoing CABG between 2012-2013.
- Major bleeding complications were defined using the Bleeding Academic Research Consortium-CABG criteria.
- Analysis compared bleeding rates based on drug (ticagrelor vs. clopidogrel) and discontinuation time (<24h, 72-120h, >120h before surgery).
Main Results:
- The incidence of major bleeding complications was high (38% and 31%) when ticagrelor/clopidogrel was discontinued less than 24 hours before surgery.
- For ticagrelor, no significant difference in bleeding was observed between discontinuation at 72-120 hours versus >120 hours (OR 0.93; P=0.80).
- Clopidogrel discontinuation at 72-120 hours was associated with a higher bleeding incidence compared to >120 hours (OR 1.71; P=0.033).
- Overall major bleeding complications were lower with ticagrelor (12.9%) compared to clopidogrel (17.6%) (adjusted OR 0.72; P=0.012).
Conclusions:
- Discontinuing ticagrelor or clopidogrel less than 24 hours before CABG is associated with a high incidence of major bleeding.
- Discontinuation 3 days before surgery did not increase bleeding complications for ticagrelor but increased risk for clopidogrel.
- Ticagrelor is associated with a lower overall risk of major bleeding complications following CABG compared to clopidogrel.
Aims:
Excessive 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 Results:
All 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].
Conclusion:
The 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.
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