Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting

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 BanconeGiuseppe Gatti, Luca Maschietto, Francesco Santini, Francesco Nicolini, Tiziano Gherli, Marco Zanobini, Eeva Maija Kinnunen, Vito G. Ruggieri, Stefano Rosato, Fausto Biancari

Research output: Contribution to journalArticle

Abstract

Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.

Objective: To 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 Participants: This 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.

Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.

Main Outcomes and Measures: Severe 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.

Results: Of 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 Relevance: In 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.

Original languageEnglish
Pages (from-to)921-928
Number of pages8
JournalJAMA Cardiology
Volume1
Issue number8
DOIs
Publication statusPublished - Nov 1 2016

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Acute Coronary Syndrome
Coronary Artery Bypass
Aspirin
Hemorrhage
Safety
Platelet Transfusion
Propensity Score
Ambulatory Surgical Procedures
Thoracic Surgery
Multicenter Studies
Registries
Ticagrelor
Platelet Aggregation Inhibitors
Incidence
Cohort Studies
Outcome Assessment (Health Care)
Clinical Trials

Keywords

  • Journal Article

Cite this

Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting. / Gherli, Riccardo; Mariscalco, Giovanni; Dalén, Magnus; Onorati, Francesco; Perrotti, Andrea; Chocron, Sidney; Verhoye, Jean Philippe; Gulbins, Helmut; Reichart, Daniel; Svenarud, Peter; Faggian, Giuseppe; Santarpino, Giuseppe; Fischlein, Theodor; Maselli, Daniele; Dominici, Carmelo; Musumeci, Francesco; Rubino, Antonino S.; Mignosa, Carmelo; De Feo, Marisa; Bancone, Ciro; Gatti, Giuseppe; Maschietto, Luca; Santini, Francesco; Nicolini, Francesco; Gherli, Tiziano; Zanobini, Marco; Kinnunen, Eeva Maija; Ruggieri, Vito G.; Rosato, Stefano; Biancari, Fausto.

In: JAMA Cardiology, Vol. 1, No. 8, 01.11.2016, p. 921-928.

Research output: Contribution to journalArticle

Gherli, R, Mariscalco, G, Dalén, M, Onorati, F, Perrotti, A, Chocron, S, Verhoye, JP, Gulbins, H, Reichart, D, Svenarud, P, Faggian, G, Santarpino, G, Fischlein, T, Maselli, D, Dominici, C, Musumeci, F, Rubino, AS, Mignosa, C, De Feo, M, Bancone, C, Gatti, G, Maschietto, L, Santini, F, Nicolini, F, Gherli, T, Zanobini, M, Kinnunen, EM, Ruggieri, VG, Rosato, S & Biancari, F 2016, 'Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting', JAMA Cardiology, vol. 1, no. 8, pp. 921-928. https://doi.org/10.1001/jamacardio.2016.3028
Gherli, Riccardo ; Mariscalco, Giovanni ; Dalén, Magnus ; Onorati, Francesco ; Perrotti, Andrea ; Chocron, Sidney ; Verhoye, Jean Philippe ; Gulbins, Helmut ; Reichart, Daniel ; Svenarud, Peter ; Faggian, Giuseppe ; Santarpino, Giuseppe ; Fischlein, Theodor ; Maselli, Daniele ; Dominici, Carmelo ; Musumeci, Francesco ; Rubino, Antonino S. ; Mignosa, Carmelo ; De Feo, Marisa ; Bancone, Ciro ; Gatti, Giuseppe ; Maschietto, Luca ; Santini, Francesco ; Nicolini, Francesco ; Gherli, Tiziano ; Zanobini, Marco ; Kinnunen, Eeva Maija ; Ruggieri, Vito G. ; Rosato, Stefano ; Biancari, Fausto. / Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting. In: JAMA Cardiology. 2016 ; Vol. 1, No. 8. pp. 921-928.
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abstract = "Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To 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 Participants: This 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.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe 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.Results: Of 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 Relevance: In 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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T1 - Safety of Preoperative Use of Ticagrelor With or Without Aspirin Compared With Aspirin Alone in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Grafting

AU - Gherli, Riccardo

AU - Mariscalco, Giovanni

AU - Dalén, Magnus

AU - Onorati, Francesco

AU - Perrotti, Andrea

AU - Chocron, Sidney

AU - Verhoye, Jean Philippe

AU - Gulbins, Helmut

AU - Reichart, Daniel

AU - Svenarud, Peter

AU - Faggian, Giuseppe

AU - Santarpino, Giuseppe

AU - Fischlein, Theodor

AU - Maselli, Daniele

AU - Dominici, Carmelo

AU - Musumeci, Francesco

AU - Rubino, Antonino S.

AU - Mignosa, Carmelo

AU - De Feo, Marisa

AU - Bancone, Ciro

AU - Gatti, Giuseppe

AU - Maschietto, Luca

AU - Santini, Francesco

AU - Nicolini, Francesco

AU - Gherli, Tiziano

AU - Zanobini, Marco

AU - Kinnunen, Eeva Maija

AU - Ruggieri, Vito G.

AU - Rosato, Stefano

AU - Biancari, Fausto

PY - 2016/11/1

Y1 - 2016/11/1

N2 - Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To 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 Participants: This 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.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe 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.Results: Of 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 Relevance: In 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.

AB - Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To 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 Participants: This 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.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe 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.Results: Of 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 Relevance: In 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.

KW - Journal Article

U2 - 10.1001/jamacardio.2016.3028

DO - 10.1001/jamacardio.2016.3028

M3 - Article

C2 - 27653165

VL - 1

SP - 921

EP - 928

JO - JAMA Cardiology

JF - JAMA Cardiology

SN - 2380-6583

IS - 8

ER -