Riccardo Gherli1, Giovanni Mariscalco2, Magnus Dalén3, Francesco Onorati4, Andrea Perrotti5, Sidney Chocron5, Jean Philippe Verhoye6, Helmut Gulbins7, Daniel Reichart7, Peter Svenarud3, Giuseppe Faggian3, Giuseppe Santarpino8, Theodor Fischlein8, Daniele Maselli9, Carmelo Dominici9, Francesco Musumeci1, Antonino S Rubino10, Carmelo Mignosa10, Marisa De Feo11, Ciro Bancone11, Giuseppe Gatti12, Luca Maschietto12, Francesco Santini13, Francesco Nicolini14, Tiziano Gherli14, Marco Zanobini15, Eeva-Maija Kinnunen16, Vito G Ruggieri6, Stefano Rosato17, Fausto Biancari16. 1. Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Forlanini Hospital, Rome, Italy. 2. Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, England. 3. 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. 4. Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy. 5. Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France. 6. Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France. 7. Hamburg University Heart Center, Hamburg, Germany. 8. Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany. 9. Department of Cardiac Surgery, St Anna Hospital, Catanzaro, Italy. 10. Centro Cuore Morgagni, Pedara, Italy. 11. Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy. 12. Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy. 13. Division of Cardiac Surgery, University of Genoa, Genoa, Italy. 14. Division of Cardiac Surgery, University of Parma, Parma, Italy. 15. Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy. 16. Department of Surgery, Oulu University Hospital, Oulu, Finland. 17. National Institute of Health, Rome, Italy.
Abstract
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.
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.
Authors: Paolo Nardi; Calogera Pisano; Maria Turturici; Fabio Bertoldo; Vito Renato Maggio; Carlo Bassano; Dario Buioni; Antonio Scafuri; Claudia Altieri; Giovanni Ruvolo Journal: Kardiochir Torakochirurgia Pol Date: 2021-10-05