In patients suffering from acute coronary syndrome (ACS) with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction or stroke, without an
increase in the rate of overall major bleeding. In the clinical guidelines, it is recommended that clopidogrel and ticagrelor be discontinued 5 days before elective surgery – a strategy that is often not applicable.

In a prospective observational study, Hansson and co-workers investigated the prevalence of major surgery-related bleeding complications in 405 patients with ACS having undergone coronary artery bypass graft (CABG) surgery while on aspirin/ticagrelor (n = 173) or aspirin/clopidogrel (n = 232), with presurgical interruption of ticagrelor or clopidogrel ranging between 0 and 5 days.

Overall, there was no difference in the prevalence of major CABG-related blood loss (postoperative blood loss ≥1500 mL/12 h, re-exploration, RBC transfusion ≥10 units, death due to bleeding) attributable to one of the investigated drugs, ticagrelor (14.5%) or clopidogrel (13.8%). When CABG was performed on ticagrelor or clopidogrel, i.e. with a presurgical interruption of 0-1 day (20% of patients!), there was a strong trend (not statistically significant) towards higher incidence of major bleeding on ticagrelor. With presurgical interruption ≥2 days (80% of patients), there was no difference between ticagrelor and clopidogrel with regard to major post-CABG bleeding.

If a 5-day pre-CABG interruption of ticagrelor or clopidogrel is impossible, a 2-4 day interruption is better than a 0-1 day interruption with regard to the incidence of major post-CABG bleeding. If CABG is performed on ticagrelor or clopidogrel, post-CABG bleeding tendency is higher on ticagrelor.

– Oliver Habler

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