Manne Holm1, Fausto Biancari2, Sorosh Khodabandeh3, Riccardo Gherli4, Juhani Airaksinen5, Giovanni Mariscalco6, Giuseppe Gatti7, Daniel Reichart8, Francesco Onorati9, Marisa De Feo10, Giuseppe Santarpino11, Antonino S Rubino12, Daniele Maselli13, Francesco Santini14, Francesco Nicolini15, Marco Zanobini16, Eeva-Maija Kinnunen17, Vito G Ruggieri18, Andrea Perrotti19, Stefano Rosato20, Magnus Dalén21. 1. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. 2. Heart Center, Turku University Hospital, University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland. 3. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiac Surgery, Karolinska University Hospital, Stockholm, Sweden. 4. Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy. 5. Heart Center, Turku University Hospital, University of Turku, Turku, Finland. 6. Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom. 7. Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy. 8. Hamburg University Heart Center, Hamburg, Germany. 9. Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy. 10. Department of Cardiothoracic Sciences, University of Caserta, Caserta, Italy. 11. Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany; Città di Lecce Hospital GVM Care & Research, Lecce, Italy. 12. Centro Clinico-Diagnostico "G.B. Morgagni", Centro Cuore, Pedara, Italy. 13. Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy. 14. Division of Cardiac Surgery, University of Genoa, Genoa, Italy. 15. Division of Cardiac Surgery, University of Parma, Parma, Italy. 16. Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy. 17. Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland. 18. Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, and Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France. 19. Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France. 20. National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy. 21. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiac Surgery, Karolinska University Hospital, Stockholm, Sweden. Electronic address: magnus.dalen@sll.se.
Abstract
BACKGROUND: We evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y12 inhibitors. METHODS: All patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y12 inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates. RESULTS: Of 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score-matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031). CONCLUSIONS: In patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.
BACKGROUND: We evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y12 inhibitors. METHODS: All patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y12 inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates. RESULTS: Of 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score-matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031). CONCLUSIONS: In patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.
Authors: Mario Gaudino; Joanna Chikwe; Volkmar Falk; Jennifer S Lawton; John D Puskas; David P Taggart Journal: Eur J Cardiothorac Surg Date: 2020-06-01 Impact factor: 4.191
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
Authors: Michael Schoerghuber; Gudrun Pregartner; Andrea Berghold; Ines Lindenau; Robert Zweiker; Andreas Voetsch; Elisabeth Mahla; Andreas Zirlik Journal: BMJ Open Date: 2022-03-28 Impact factor: 2.692