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How Do Type of Preoperative P2Y12 Receptor Inhibitor and Withdrawal Time Affect Bleeding?
Andreas Voetsch1, Gudrun Pregartner2, Andrea Berghold2
1Department of Cardiac Surgery, Medical University of Graz, Austria; Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria.
Insights
Discontinuing P2Y12 inhibitors like prasugrel and ticagrelor less than 48 hours before coronary artery bypass grafting (CABG) increases blood loss and bleeding. Waiting longer than 48 hours significantly reduces these risks.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) discontinuation before coronary artery bypass grafting (CABG) varies significantly between institutions.
- Standardized preoperative waiting periods for ticagrelor, clopidogrel, and prasugrel are recommended but inconsistently followed.
Purpose of the Study:
- To evaluate the impact of preoperative P2Y12 inhibitor discontinuation timing on calculated blood loss and Bleeding Academic Research Consortium type 4 (BARC-4) bleeding in patients undergoing CABG.
- To compare outcomes among different P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) based on their preoperative withdrawal time.
Main Methods:
- A retrospective study of 299 patients undergoing CABG with or without valve intervention within 7 days of their last P2Y12 inhibitor dose.
- Analysis of calculated red blood cell loss and incidence of BARC-4 bleeding.
- Multivariable regression analysis to identify factors associated with blood loss, including P2Y12 inhibitor type and withdrawal duration.
Main Results:
- 83% of patients underwent CABG less than 48 hours after their last drug intake.
- Clopidogrel use was associated with significantly lower calculated blood loss compared to prasugrel or ticagrelor.
- A preoperative discontinuation period exceeding 48 hours substantially reduced calculated blood loss (37-48%) and BARC-4 bleeding (58-71%) across all P2Y12 inhibitors.
Conclusions:
- Exposure to prasugrel and ticagrelor within 24 hours before CABG significantly increases blood loss and BARC-4 bleeding compared to clopidogrel.
- Discontinuing P2Y12 inhibitors for over 48 hours pre-CABG is associated with substantially reduced blood loss and bleeding.
- Adherence to preoperative discontinuation guidelines is crucial for optimizing patient outcomes in CABG, especially when hemodynamics are stable.
Background:
Despite recommendations for standardized preoperative waiting of at least 3, 5, and 7 days for ticagrelor, clopidogrel, and prasugrel, respectively, there is still substantial interinstitutional variation in preoperative discontinuation of dual antiplatelet therapy in patients needing coronary artery bypass grafting (CABG).
Methods:
In 299 patients undergoing CABG with or without valve intervention less than 7 days after last P2Y12 receptor inhibition, this study evaluated calculated red blood cell loss and Bleeding Academic Research Consortium type 4 (BARC-4) bleeding.
Results:
A total of 83% of patients underwent CABG less than 48 hours after last drug intake. Calculated blood loss was lower in patients taking clopidogrel as compared with prasugrel or ticagrelor (1063 mL [690 to 1394 mL] vs 1351 mL [876 to 1829 mL] vs 1330 mL [994 to 1691 mL]; P < .001). Overall, 135 (45%) patients sustained BARC-4 bleeding; the incidence differed among the groups (P = .015) and was significantly higher in prasugrel-treated patients, as compared with clopidogrel-treated patients. In multivariable linear regression analysis, European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), aspirin dose, cardiopulmonary bypass time, drug withdrawal time, and type of P2Y12 receptor inhibitor were significantly associated with red blood cell loss. Compared with 0 to 24 hours, a period of more than 48 hours of preoperative discontinuation substantially reduced calculated blood loss by 37% to 48% and BARC-4 bleeding by 58% to 71%, depending on the P2Y12 receptor inhibitor.
Conclusions:
Exposure to prasugrel and ticagrelor 24 hours or less before CABG increases both calculated blood loss and BARC-4 bleeding as compared with clopidogrel. Although discontinuation for longer than 48 hours substantially reduced calculated blood loss and BARC-4 bleeding across all P2Y12 receptor inhibitors, our single-center data further support strict adherence to the 2017 guidelines whenever justified by stable hemodynamics and nonjeopardized myocardium.
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