Bleeding in Patients Treated with Ticagrelor or Clopidogrel Before Coronary Artery Bypass Grafting.

BACKGROUND: We evaluated perioperative bleeding after 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. Primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding (UDPB), 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 pre- and perioperative covariates. RESULTS: 2311 patients were included, of whom 1293 (55.9%) received clopidogrel and 1018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and surgery 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 UDPB when ticagrelor was discontinued 0-2 days compared with 3 days before surgery (16.0 vs. 2.7%, p=0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to UDPB when clopidogrel was discontinued 0-3 days compared with 4-5 days before surgery (15.6 vs. 8.3%, p=0.031). CONCLUSIONS: In patients receiving ticagrelor 2 days before surgery and in those receiving clopidogrel 3 days before surgery, there was an increased rate of severe bleeding. Postponing non-emergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.