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Observational Study
. 2016 Jan 7;37(2):189-97.
doi: 10.1093/eurheartj/ehv381. Epub 2015 Sep 1.

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study

Emma C Hansson  1 , Lena Jidéus  2 , Bengt Åberg  3 , Henrik Bjursten  4 , Mats Dreifaldt  5 , Anders Holmgren  6 , Torbjörn Ivert  7 , Shahab Nozohoor  4 , Mikael Barbu  3 , Rolf Svedjeholm  8 , Anders Jeppsson  9
Affiliations
Observational Study

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study

Emma C Hansson et al. Eur Heart J. .

Abstract

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.

Keywords: Acute coronary syndrome; Bleeding complications; Cardiac surgery; Dual antiplatelet therapy.

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Figures

Figure 1
Figure 1
Incidence of major bleeding complications according to BARC-CABG, BART, PLATO life-threatening, and PLATO major bleeding (P-values from Fisher's exact test between ticagrelor and clopidogrel). BARC, Bleeding Academic Research Consortium; CABG, coronary artery bypass grafting; BART, Blood Conservation Using Antifibrinolytics in a Randomized Trial; PLATO, PLATelet inhibition and patient Outcomes.
Figure 2
Figure 2
Incidence of BARC-CABG major bleeding by day of discontinuation of clopidogrel/ticagrelor to surgery (P-values from Fisher's exact test). BARC, Bleeding Academic Research Consortium; CABG, coronary artery bypass grafting.
Figure 3
Figure 3
Incidence of BARC-CABG major bleeding stratified by time from discontinuation of clopidogrel/ticagrelor to surgery (P-values denoting difference between the platelet inhibitors, and within clopidogrel/ticagrelor between discontinuation strata as indicated). BARC, Bleeding Academic Research Consortium; CABG, coronary artery bypass grafting.
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