Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study.
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.
['Hansson|Emma C|EC|', 'Jidéus|Lena|L|', 'Åberg|Bengt|B|', 'Bjursten|Henrik|H|', 'Dreifaldt|Mats|M|', 'Holmgren|Anders|A|', 'Ivert|Torbjörn|T|', 'Nozohoor|Shahab|S|', 'Barbu|Mikael|M|', 'Svedjeholm|Rolf|R|', 'Jeppsson|Anders|A|']
D000241:Adenosine D000368:Aged D001803:Blood Transfusion D000077144:Clopidogrel D001026:Coronary Artery Bypass D005260:Female D006801:Humans D008297:Male D010975:Platelet Aggregation Inhibitors D019106:Postoperative Hemorrhage D012042:Registries D012086:Reoperation D012189:Retrospective Studies D013548:Sweden D000077486:Ticagrelor D013988:Ticlopidine D013997:Time Factors
Bleeding complications Acute coronary syndrome Dual antiplatelet therapy Cardiac surgery