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Original Investigation
November 2016

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

Author Affiliations
  • 1Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Forlanini Hospital, Rome, Italy
  • 2Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, England
  • 3Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  • 4Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  • 5Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
  • 6Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France
  • 7Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
  • 8Hamburg University Heart Center, Hamburg, Germany
  • 9Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
  • 10Department of Cardiac Surgery, St Anna Hospital, Catanzaro, Italy
  • 11Centro Cuore Morgagni, Pedara, Italy
  • 12Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
  • 13Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
  • 14Division of Cardiac Surgery, University of Genoa, Genoa, Italy
  • 15Division of Cardiac Surgery, University of Parma, Parma, Italy
  • 16Department of Cardiac Surgery, Centro Cardiologico–Fondazione Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy
  • 17Department of Surgery, Oulu University Hospital, Oulu, Finland
  • 18National Institute of Health, Rome, Italy
JAMA Cardiol. 2016;1(8):921-928. doi:10.1001/jamacardio.2016.3028
Key Points

Question  What is the normal timing of discontinuation of antiplatelet drug use in acute coronary syndromes before coronary artery bypass grafting?

Findings  In this multicenter clinical trial that included 786 adult patients, administration of ticagrelor with or without aspirin was associated with the same risk of bleeding and major complication after cardiac surgery compared with aspirin alone. However, the risk was significantly increased among patients in whom ticagrelor was administered 1 day before or up until surgery.

Meaning  The use of ticagrelor is safe before coronary artery bypass grafting, particularly if its use is discontinued more than 24 hours before surgery.


Importance  The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.

Objective  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.

Design, Setting, and Participants  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.

Exposures  Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.

Main Outcomes and Measures  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.

Results  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.

Conclusions and Relevance  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.