University of Oulu

Manne Holm, Fausto Biancari, Sorosh Khodabandeh, Riccardo Gherli, Juhani Airaksinen, Giovanni Mariscalco, Giuseppe Gatti, Daniel Reichart, Francesco Onorati, Marisa De Feo, Giuseppe Santarpino, Antonino S. Rubino, Daniele Maselli, Francesco Santini, Francesco Nicolini, Marco Zanobini, Eeva-Maija Kinnunen, Vito G. Ruggieri, Andrea Perrotti, Stefano Rosato, Magnus Dalén, Bleeding in Patients Treated With Ticagrelor or Clopidogrel Before Coronary Artery Bypass Grafting, The Annals of Thoracic Surgery, Volume 107, Issue 6, 2019, Pages 1690-1698, ISSN 0003-4975,

Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting

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Author: Holm, Manne1; Biancari, Fausto2,3,4; Khodabandeh, Sorosh1,5;
Organizations: 1Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
2Heart Center, Turku University Hospital, University of Turku, Turku, Finland
3Department of Surgery, University of Turku, Turku, Finland
4Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
5Department of Cardiac Surgery, Karolinska University Hospital, Stockholm, Sweden
6Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
7Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
8Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
9Hamburg University Heart Center, Hamburg, Germany
10Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
11Department of Cardiothoracic Sciences, University of Caserta, Caserta, Italy
12Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
13Città di Lecce Hospital GVM Care & Research, Lecce, Italy
14Centro Clinico-Diagnostico “G.B. Morgagni”, Centro Cuore, Pedara, Italy
15Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
16Division of Cardiac Surgery, University of Genoa, Genoa, Italy
17Division of Cardiac Surgery, University of Parma, Parma, Italy
18Department of Cardiac Surgery, Centro Cardiologico–Fondazione Monzino Istituto di Ricovero e Cura a Carattere Scientifico, University of Milan, Milan, Italy
19Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, and Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
20Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
21National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
Format: article
Version: accepted version
Access: open
Online Access: PDF Full Text (PDF, 1.4 MB)
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Language: English
Published: Elsevier, 2019
Publish Date: 2020-06-30


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.

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Series: The annals of thoracic surgery
ISSN: 0003-4975
ISSN-E: 1552-6259
ISSN-L: 0003-4975
Volume: 107
Issue: 6
Pages: 1690 - 1698
DOI: 10.1016/j.athoracsur.2019.01.086
Type of Publication: A1 Journal article – refereed
Field of Science: 3126 Surgery, anesthesiology, intensive care, radiology
Copyright information: © 2019 by The Society of Thoracic Surgeons. Published by Elsevier Inc. This manuscript version is made available under the CC-BY-NC-ND 4.0 license