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CABG-related bleeding complications in ACS higher with clopidogrel vs. ticagrelor
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Risk for major CABG-related bleeding complications was lower for patients with ACS on ticagrelor than for those on clopidogrel, but discontinuation of either drug less than 24 hours before surgery was associated with a high rate of bleeding complications, researchers found.
Current guidelines recommend stopping clopidogrel and ticagrelor (Brilinta, AstraZeneca) 5 days before elective surgery, but the researchers investigated whether a shorter discontinuation time, which could reduce risk for thrombotic events and save hospital resources, would affect the rate of CABG-related bleeding complications.
Emma C. Hansson, MD, and colleagues conducted a retrospective observational study of all patients with ACS in Sweden who underwent CABG in 2012 and 2013 while being treated with dual antiplatelet therapy consisting of aspirin plus ticagrelor (n = 1,266) or aspirin plus clopidogrel (n = 978) within 14 days before surgery. Of those assigned clopidogrel, 44% had it discontinued less than 5 days before surgery, whereas of those assigned ticagrelor, 33% had it discontinued less than 5 days before surgery.
Patients were stratified by antiplatelet agent and by time between discontinuation of ticagrelor or clopidogrel and performance of CABG. The primary outcome was incidence of major bleeding complications.
When antiplatelet therapy was discontinued less than 24 hours before surgery, the incidence of major bleeding complications as defined by Bleeding Academic Research Consortium–CABG was 38% for those assigned ticagrelor and 31% for those assigned clopidogrel, Hansson, from the department of cardiothoracic surgery, Sahlgrenska University Hospital in Gothenburg, Sweden, and colleagues found.
For those assigned ticagrelor, there was no difference in major bleeding incidence between those for whom it was discontinued 72 to 120 hours before surgery and those for whom it was discontinued more than 120 hours before surgery (OR = 0.93; 95% CI, 0.53-1.64), according to the researchers.
However, they found, for those assigned clopidogrel, those for whom it was discontinued 72 to 120 hours before surgery had a higher incidence of major bleeding than those for whom it was discontinued more than 120 hours before surgery (OR = 1.71; 95% CI, 1.04-2.79).
The overall incidence of major bleeding complications was lower with ticagrelor than with clopidogrel (12.9% vs. 17.6%; adjusted OR = 0.72; 95% CI, 0.56-0.92), Hansson and colleagues wrote.
The results suggest “that it is safe to operate on ACS patients treated with ticagrelor earlier after discontinuation than is currently recommended in guidelines,” they wrote. “A reduction in waiting time from 5 to 3 days would reduce the risk for thrombotic events while waiting for CABG, and save hospital resources.” – by Erik Swain
Disclosure: The study was funded in part by AstraZeneca. Hansson reports receiving speaker’s honoraria from AstraZeneca. Another researcher reports receiving speaker’s honoraria and research support from AstraZeneca.
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