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JACC April 5, 2016

Volume 67, Issue 13

Acute Coronary Syndromes

CLINICAL OUTCOMES FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN RELATION TO
TIMING OF SURGERY FOLLOWING TICAGRELOR DISCONTINUATION: INSIGHTS FROM THE
UNIVERSITY OF OTTAWA HEART INSTITUTE REGISTRY
Moderated Poster Contributions
Acute Coronary Syndromes Moderated Poster Theater, Poster Area, South Hall A1
Sunday, April 03, 2016, 1:00 p.m.-1:10 p.m.
Session Title: A Moving Target: Antithrombotics in ACS
Abstract Category: 14. Acute Coronary Syndromes: Clinical
Presentation Number: 1203M-05
Authors: Juan Russo, Tyler E. James, Nikita Malhotra, Daniel Goubran, Fraser Rubens, Michael Bourke, Jean-Yves Dupuis, Vincent Chan,
Singh Kuljit, Marc Ruel, Benjamin Hibbert, Aun-Yeong Chong, Derek So, University of Ottawa Heart Institute, Ottawa, Canada
Background: We assessed clinical outcomes in ACS patients treated with ticagrelor and undergoing in-hospital CABG in relation to the
duration of ticagrelor discontinuation prior to surgery.

Methods: We identified consecutive ACS patients undergoing CABG after having received ticagrelor. Patients were stratified based on
the timing of surgery after discontinuation of ticagrelor (<48 hours, 2-4 days, 5 days). We then compared efficacy and safety outcomes
following CABG in relation to the duration of ticagrelor discontinuation prior to surgery. The primary outcome was the incidence of major
adverse cardiovascular events (MACE) defined as the composite of death, myocardial infarction, need for coronary revascularization, or
stroke.

Results: Of 546 ACS patients undergoing CABG between January 2012 and March 2015, 95 received ticagrelor. Ticagrelor was
discontinued <48 hours prior to CABG in 26% of patients; 2-4 days in 26%; and 5 days in 48%. There was no association between
the duration of ticagrelor discontinuation prior to CABG and the rate of MACE (p=0.89). Compared to patients in the 2-4 day ticagrelor
discontinuation group, patients undergoing CABG 5 days following ticagrelor discontinuation had numerically higher rates of MACE (8%
vs 4.4%) but the difference was not statistically significant (p=0.61). Patients undergoing CABG <48 hours after ticagrelor discontinuation
had significantly higher rates of Universal Definition of Perioperative Bleeding (UDPB) 2 (52%; p=0.003); however, the rates of bleeding
with ticagrelor discontinuation periods of 2-4 days and 5 days prior to CABG were comparable (20% vs 15.6%; p=0.74).

Conclusions: A significant number of ACS patients (52%) requiring CABG underwent surgery before the guideline recommended ticagrelor
discontinuation period of 5 days. Patients who underwent CABG <48 hours after ticagrelor discontinuation had higher rates of bleeding; in
contrast, bleeding was comparable in patients undergoing CABG following 2-4 days versus 5 days of ticagrelor discontinuation. Delays in
CABG in ACS beyond 48 hours of ticagrelor discontinuation to prevent bleeding should be weighed against potential increases in adverse
cardiovascular events.

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