• Riccardo Gherli, Giovanni Mariscalco, Magnus Dalén, Francesco Onorati, Andrea Perrotti, Sidney Chocron, Jean Philippe Verhoye, Helmut Gulbins, Daniel Reichart, Peter Svenarud, Giuseppe Faggian, Giuseppe Santarpino, Theodor Fischlein, Daniele Maselli, Carmelo Dominici, Francesco Musumeci, Antonino S Rubino, Carmelo Mignosa, Marisa De Feo, Ciro Bancone, Giuseppe Gatti, Luca Maschietto, Francesco Santini, Francesco Nicolini, Tiziano Gherli, Marco Zanobini, Eeva-Maija Kinnunen, Vito G Ruggieri, Stefano Rosato, and Fausto Biancari.
• Department of Cardiovascular Sciences, Cardiac Surgery Unit, San Camillo Forlanini Hospital, Rome, Italy.
• JAMA Cardiol. 2016 Nov 1; 1 (8): 921-928.

ImportanceThe optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.ObjectiveTo 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 ParticipantsThis 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.ExposuresBefore surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes And MeasuresSevere 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.ResultsOf 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 RelevanceIn 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.

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