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


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].


CONCLUSIONS
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.
Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden.
Emma C
EC
Hansson
Department of Cardiothoracic Surgery, University Hospital, Uppsala, Sweden.
Lena
L
Jidéus
Department of Cardiothoracic Surgery, Blekinge Hospital, Karlskrona, Sweden.
Bengt
B
Åberg
Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden.
Henrik
H
Bjursten
Department of Cardiothoracic Surgery, University Hospital and University Health Care Research Centre, Örebro, Sweden.
Mats
M
Dreifaldt
Department of Cardiothoracic Surgery, University Hospital, Umeå, Sweden.
Anders
A
Holmgren
Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
Torbjörn
T
Ivert
Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden.
Shahab
S
Nozohoor
Department of Cardiothoracic Surgery, Blekinge Hospital, Karlskrona, Sweden.
Mikael
M
Barbu
Department of Cardiothoracic Surgery, University Hospital, Linköping, Sweden.
Rolf
R
Svedjeholm
Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, SE-413 45 Gothenburg, Sweden Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden anders.jeppsson@vgregion.se.
Anders
A
Jeppsson
D000241:Adenosine / Q000009:adverse effects / Q000031:analogs & derivatives*; D000368:Aged; D001803:Blood Transfusion / Q000706:statistics & numerical data; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000517:prevention & control*; D012042:Registries; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013548:Sweden; D000077486:Ticagrelor; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine
Acute coronary syndrome; Bleeding complications; Cardiac surgery; Dual antiplatelet therapy