title: Perioperative outcomes of cardiac surgery patients with ongoing ticagrelor therapy: boon and bane of a new drug.
abstract: OBJECTIVE
  Ticagrelor (Brilique®) is a novel reversible platelet inhibitor at P2Y12 receptor used in patients with acute coronary syndrome and patients undergoing percutaneous coronary interventions. Unlike clopidogrel (Plavix®), ticagrelor has a quicker offset of action, and therefore, it seems that platelet function recovers faster on discontinuation of therapy. These drugs sometimes cannot be stopped before coronary artery bypass grafting due to the risk of stent thrombosis or in case of emergency operations. Therefore, we investigated whether the continued preoperative use of ticagrelor influences the perioperative course of cardiac surgical patients.
  
  
  METHODS
  The perioperative course and clinical outcomes of patients preoperatively receiving ticagrelor + acetylsalicylic acid (ASA) (n = 32) or clopidogrel + ASA (n = 49) until cardiac surgery, performed at University of Goettingen between January 2012 and December 2012, were studied. The study was designed as a retrospective observational study. The observation period started with the surgery and ended after 3 days. P < 0.05 was considered statistically significant.
  
  
  RESULTS
  Preoperative data and intraoperative characteristics were almost similar among the groups. In the first 24 h, the median blood loss was 850 [780-1600] ml in the ticagrelor group and 680 [400-860] ml in the clopidogrel group (P = 0.0006). Furthermore, the median red blood cell transfusion (P = 0.0031), the median pooled platelet transfusion (P = 0.0012), the median prothrombin complex concentrate use (P = 0.0114) and the median fibrinogen use (P = 0.0118) were significantly higher in the ticagrelor group compared with the clopidogrel group. However, there was no statistical significance between the two groups regarding intensive care unit and hospital stay, mechanical ventilation time, incidence of acute kidney injury and mortality. Hence, a tendency towards more rethoracotomies due to bleeding in the ticagrelor group was observed (P = 0.0632).
  
  
  CONCLUSIONS
  In cardiac surgical patients who are treated with ticagrelor + ASA until surgery, ticagrelor therapy is associated with a significantly higher blood loss, a significantly higher use of blood products and coagulation factors and higher incidence of rethoracotomies for bleeding compared with patients treated with clopidogrel + ASA.
authors.affiliation: Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Goettingen, Goettingen, Germany hschotola@med.uni-goettingen.de.
authors.forename: Hanna
authors.initials: H
authors.lastname: Schotola
authors.affiliation: Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Anselm
authors.initials: A
authors.lastname: Bräuer
authors.affiliation: Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Katharina
authors.initials: K
authors.lastname: Meyer
authors.affiliation: Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: José
authors.initials: J
authors.lastname: Hinz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Friedrich Albert
authors.initials: FA
authors.lastname: Schöndube
authors.affiliation: Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Bauer
authors.affiliation: Department of Cardiothoracic Transplantation and Mechanical Support, Brompton and Harefield Hospital, Harefield, London, UK.
authors.forename: Prashant Nanasaheb
authors.initials: PN
authors.lastname: Mohite
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Bernd Christoph
authors.initials: BC
authors.lastname: Danner
authors.affiliation: Department of Cardiology and Respiratory Medicine, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Samuel
authors.initials: S
authors.lastname: Sossalla
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Georg-August-University Goettingen, Goettingen, Germany.
authors.forename: Aron Frederik
authors.initials: AF
authors.lastname: Popov
mesh_terms: D000241:Adenosine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D001803:Blood Transfusion / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data*; D005260:Female; D006470:Hemorrhage; D006801:Humans; D008297:Male; D008875:Middle Aged; D059035:Perioperative Period / Q000706:statistics & numerical data*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D012189:Retrospective Studies; D000077486:Ticagrelor; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077486:Ticagrelor; D000241:Adenosine; D001241:Aspirin
keywords: CABG; Continued ticagrelor application; Perioperative outcome