title: Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting.
abstract: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.
  
  
  
  To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone.
  
  
  
  This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.
  
  
  
  Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.
  
  
  
  Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.
  
  
  
  Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group.
  
  
  
  In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.
authors.affiliation: Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Forlanini Hospital, Rome, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Gherli
authors.affiliation: Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, England.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Mariscalco
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden4Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: Dalén
authors.affiliation: Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Onorati
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France.
authors.forename: Andrea
authors.initials: A
authors.lastname: Perrotti
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France.
authors.forename: Sidney
authors.initials: S
authors.lastname: Chocron
authors.affiliation: Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France.
authors.forename: Jean Philippe
authors.initials: JP
authors.lastname: Verhoye
authors.affiliation: Hamburg University Heart Center, Hamburg, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Gulbins
authors.affiliation: Hamburg University Heart Center, Hamburg, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Reichart
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden4Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Peter
authors.initials: P
authors.lastname: Svenarud
authors.affiliation: Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden4Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
authors.affiliation: Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Santarpino
authors.affiliation: Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Department of Cardiac Surgery, St Anna Hospital, Catanzaro, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Maselli
authors.affiliation: Department of Cardiac Surgery, St Anna Hospital, Catanzaro, Italy.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Dominici
authors.affiliation: Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Forlanini Hospital, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Musumeci
authors.affiliation: Centro Cuore Morgagni, Pedara, Italy.
authors.forename: Antonino S
authors.initials: AS
authors.lastname: Rubino
authors.affiliation: Centro Cuore Morgagni, Pedara, Italy.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Mignosa
authors.affiliation: Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy.
authors.forename: Marisa
authors.initials: M
authors.lastname: De Feo
authors.affiliation: Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy.
authors.forename: Ciro
authors.initials: C
authors.lastname: Bancone
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gatti
authors.affiliation: Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Maschietto
authors.affiliation: Division of Cardiac Surgery, University of Genoa, Genoa, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Santini
authors.affiliation: Division of Cardiac Surgery, University of Parma, Parma, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Nicolini
authors.affiliation: Division of Cardiac Surgery, University of Parma, Parma, Italy.
authors.forename: Tiziano
authors.initials: T
authors.lastname: Gherli
authors.affiliation: Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Zanobini
authors.affiliation: Department of Surgery, Oulu University Hospital, Oulu, Finland.
authors.forename: Eeva-Maija
authors.initials: EM
authors.lastname: Kinnunen
authors.affiliation: Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France.
authors.forename: Vito G
authors.initials: VG
authors.lastname: Ruggieri
authors.affiliation: National Institute of Health, Rome, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Rosato
authors.affiliation: Department of Surgery, Oulu University Hospital, Oulu, Finland.
authors.forename: Fausto
authors.initials: F
authors.lastname: Biancari
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000241:Adenosine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000627:therapeutic use*; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019106:Postoperative Hemorrhage; D011446:Prospective Studies; D000077486:Ticagrelor
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077486:Ticagrelor; D000241:Adenosine; D001241:Aspirin