The association between a three-day ticagrelor discontinuation and perioperative bleeding complications

OBJECTIVES: Dual antiplatelet therapy at the time of cardiac surgery is associated with excessive perioperative bleeding. International guidelines, therefore, recommended discontinuing oral adenosine diphosphate receptor antagonists prior to non-emergency surgery. In this study, we analysed whether a 3-day ticagrelor discontinuation was sufficient to avoid major bleeding complications.

METHODS: This study is a retrospective cohort analysis of 3377 patients undergoing coronary artery bypass or single-valve surgery from January 2013 to September 2017. Patients exposed to ticagrelor prior to surgery were compared with control patients exposed to aspirin only. Outcome measures included transfusion requirements, bleeding volumes, the need for re-exploration and the composite outcome major bleeding complication. Data were retrieved from the the Western Denmark Heart Registry.

RESULTS: During the study period, 101 patients were preoperatively exposed to ticagrelor, whereas 3276 patients were exposed to aspirin only. Propensity-score matching resulted in 90 pairs of patients. Overall, ticagrelor exposure was associated with a greater risk of major bleeding complications compared with control patients [31 vs 12%, relative risk 2.6, 95% confidence interval (CI) 1.4-4.8]. While ticagrelor exposure within 0-72 h before surgery (n = 42) was associated with a substantially increased risk of major bleeding complications (48 vs 10%, relative risk 5.0, 95% CI 1.9-13.4), ticagrelor exposure 72-120 h before surgery (n = 48) showed no statistically significant association (17 vs 15%, relative risk 1.1, 95% CI 0.4-2.9).

CONCLUSIONS: In our historical cohort, ticagrelor exposure 0-72 h prior to cardiac surgery was associated with an increased risk of major bleeding complications. On the other hand, ticagrelor exposure 72-120 h prior to surgery was not associated with a clinically relevant increase in major bleeding complications.