CABG-Related Bleeding With Ticagrelor or Clopidogrel

Study Questions:

What is the effect of a shorter discontinuation time before bypass surgery on the risk of major bleeding with ticagrelor or clopidogrel?

Methods:

All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1,266) or clopidogrel (n = 978) who underwent CABG during 2012–13 were included in a retrospective observational study. Logistic regression modeling was used to identify factors related to major bleeding and to compare incidence of bleeding between discontinuation groups.

Results:

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 hours before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or >120 hours 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 hours 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).

Conclusions:

The authors concluded that the incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 hours before surgery.

Perspective:

This study reports that discontinuation of the platelet inhibitor 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications in ticagrelor-treated patients, but increased the incidence in clopidogrel-treated patients. The incidence of CABG-related major bleeding was high when either ticagrelor or clopidogrel was discontinued <24 hours before surgery. In addition, a lower incidence of major bleeding complications was observed in ticagrelor-treated patients, except when the platelet inhibitor was discontinued <72 hours before surgery.


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