Preoperative Ticagrelor Implementation Leads to a Higher Risk of Bleeding during and after Coronary Bypass Surgery in a Case Matched Analysis

Objectives: Ticagrelor is an antiplatelet agent which inhibits the adenosine diphosphate (ADP) P2Y12 platelet receptors. The German Society of Cardiology recommends Ticagrelor as standard therapy in patients with acute coronary syndrome and a moderate to severe risk of ischemic events for 12 months. These guidelines also recommend a stop of Ticagrelor intake 5 days prior to elective surgery. However, patients are undergoing frequently emergency cardiac surgery after initial Ticagrelor loading. In this article we investigated the influence of Ticagrelor on intra- und perioperative bleeding complications.

Methods: Between 01/2013 and 06/2013, cardiac surgery was performed in 28 patients with preoperative Ticagrelor intake. 24 (86%) of them were male and mean age was 73± 6.6 years. Coronary revascularization was done off-pump in 14 patients, on-pump in 10 cases and in 4 cases additional aortic valve replacement was done. 6 (21.4%) patients were transferred with a recent STEMI and 12 (43%) patients with a recent NSTEMI. 10 (35.7%) patients suffered from an instable angina pectoris, one of them after an unsuccessful PCI. The perioperative blood loss and peri- and postoperative bleeding complications were documented and a matched-pair analysis was performed with patients of same age, gender, type of surgery and without prior Ticagrelor intake.

Results: The mean number of erythrocyte and thrombocytes concentrates needed was significantly higher in the Ticagrelor group with (3.6 ± 0.2 versus 0.2 ± 0.8; p < 0.005). Bleeding complications were also more present in the Ticagrelor group (8 versus 0; p < 0.005) with 4 (14%) revisions and 4(14%) severe intraoperative bleedings. 2(7%) patients had a postoperative hemorrhagic shock with consecutive CPR. In the Ticagrelor group blood loss was significantly higher (1028.6 ± 735.5 ml versus 436.8 ± 289.3 ml; p < 0.005). No intraoperative or perioperative deaths were found through follow up.

Conclusion: Patients undergoing cardiac surgery with prior Ticagrelor intake have a significantly higher risk of bleeding complications and a significantly higher blood loss. Therefore, Ticagrelor intake should be avoided before cardiac surgery. Larger number of patients are needed to investigate the influence of Ticagrelor on perioperative morbidity and mortality.