The association between a three-day ticagrelor discontinuation and perioperative bleeding complications
Michael Kremke1, Marie Storebjerg Gissel1, Margrethe Jermiin Jensen2
1Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark.
Insights
Discontinuing ticagrelor (a P2Y12 inhibitor) less than 72 hours before cardiac surgery increases major bleeding risk. However, a 72-120 hour discontinuation period showed no significant increase in bleeding complications, suggesting a potentially safer window.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) with oral P2Y12 receptor antagonists like ticagrelor is crucial for preventing thrombotic events.
- However, DAPT increases perioperative bleeding risk during cardiac surgery, necessitating careful management.
- International guidelines recommend discontinuing P2Y12 inhibitors before non-emergency cardiac surgery to mitigate bleeding complications.
Purpose of the Study:
- To evaluate the safety of a 3-day discontinuation period for ticagrelor before cardiac surgery.
- To determine if a 72-hour ticagrelor washout is sufficient to avoid major bleeding complications.
- To compare bleeding risks between patients on ticagrelor and aspirin alone prior to cardiac surgery.
Main Methods:
- Retrospective cohort analysis of 3377 patients undergoing coronary artery bypass or single-valve surgery.
- Comparison of patients preoperatively exposed to ticagrelor versus aspirin only.
- Outcome measures included transfusion, bleeding volume, re-exploration, and major bleeding complications.
Main Results:
- Ticagrelor exposure was associated with a higher risk of major bleeding complications (31% vs 12%).
- Exposure within 0-72 hours before surgery significantly increased major bleeding risk (48% vs 10%).
- Exposure 72-120 hours before surgery showed no statistically significant increase in major bleeding risk (17% vs 15%).
Conclusions:
- Ticagrelor exposure within 72 hours prior to cardiac surgery is linked to increased major bleeding.
- A ticagrelor discontinuation window of 72-120 hours appears safe, with no clinically relevant increase in bleeding complications.
- This suggests that a longer discontinuation period may be necessary to optimize patient safety in cardiac surgery.
Objectives:
Dual antiplatelet therapy at the time of cardiac surgery is associated with excessive perioperative bleeding. International guidelines, therefore, recommended discontinuing oral adenosine diphosphate receptor antagonists prior to non-emergency surgery. In this study, we analysed whether a 3-day ticagrelor discontinuation was sufficient to avoid major bleeding complications.
Methods:
This study is a retrospective cohort analysis of 3377 patients undergoing coronary artery bypass or single-valve surgery from January 2013 to September 2017. Patients exposed to ticagrelor prior to surgery were compared with control patients exposed to aspirin only. Outcome measures included transfusion requirements, bleeding volumes, the need for re-exploration and the composite outcome major bleeding complication. Data were retrieved from the the Western Denmark Heart Registry.
Results:
During the study period, 101 patients were preoperatively exposed to ticagrelor, whereas 3276 patients were exposed to aspirin only. Propensity-score matching resulted in 90 pairs of patients. Overall, ticagrelor exposure was associated with a greater risk of major bleeding complications compared with control patients [31 vs 12%, relative risk 2.6, 95% confidence interval (CI) 1.4-4.8]. While ticagrelor exposure within 0-72 h before surgery (n = 42) was associated with a substantially increased risk of major bleeding complications (48 vs 10%, relative risk 5.0, 95% CI 1.9-13.4), ticagrelor exposure 72-120 h before surgery (n = 48) showed no statistically significant association (17 vs 15%, relative risk 1.1, 95% CI 0.4-2.9).
Conclusions:
In our historical cohort, ticagrelor exposure 0-72 h prior to cardiac surgery was associated with an increased risk of major bleeding complications. On the other hand, ticagrelor exposure 72-120 h prior to surgery was not associated with a clinically relevant increase in major bleeding complications.
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