From the Guidelines
Aspirin should be restarted as soon as possible post-operatively, ideally within 24 hours, if there is no concern over bleeding, while ticagrelor can be resumed after a careful assessment of the bleeding risk, typically within 48-72 hours, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. The decision to restart antiplatelet therapy post-operatively should be based on the individual patient's risk of bleeding and thrombotic events.
- Aspirin is recommended to be continued lifelong in patients undergoing CABG, and it should be restarted as soon as possible after surgery, ideally within 24 hours, if there is no concern over bleeding 1.
- Ticagrelor, on the other hand, is usually resumed 48-72 hours post-operatively due to its more potent antiplatelet effects, but the exact timing should be individualized based on the balance between thrombotic and bleeding risks 1.
- The use of ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and an OAC is generally not recommended, unless there is a high ischemic risk, as stated in the 2024 ESC guidelines 1.
- A proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding for the duration of combined antithrombotic therapy (antiplatelet therapy and/or OAC) 1.
- The timing of resumption of antiplatelet therapy should be made collaboratively between the surgeon and cardiologist, taking into account the patient's individual risk factors and the specific procedure performed.
- It is essential to weigh the benefits of preventing thrombotic events against the risks of bleeding when deciding on the timing of antiplatelet resumption, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.
From the Research
Administration of Antiplatelet Agents Post-Operatively
- The administration of antiplatelet agents like aspirin and ticagrelor post-operatively is a critical aspect of patient care, particularly in those who have undergone coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) 2, 3.
- Studies have shown that dual antiplatelet therapy (DAPT) with aspirin and ticagrelor or clopidogrel is effective in reducing the risk of major adverse cardiovascular events, but it is also associated with an increased risk of bleeding 4, 5.
- The optimal timing of administration of antiplatelet agents post-operatively is not well established, but it is generally recommended to start DAPT as soon as possible after CABG or PCI, usually within 24 hours 2, 3.
Ticagrelor Monotherapy vs. DAPT
- Some studies have suggested that ticagrelor monotherapy may be a viable alternative to DAPT in certain patient populations, particularly those at high risk of bleeding 3, 4.
- The TWILIGHT-CABG study found that ticagrelor monotherapy was associated with significantly less bleeding than DAPT in patients with prior CABG, without compromising ischemic outcomes 3.
- Another study found that ticagrelor monotherapy reduced bleeding without increasing the risk of ischemic events compared to DAPT in patients undergoing complex PCI 4.
Interaction between Proton Pump Inhibitors and Antiplatelet Agents
- There is ongoing debate about the potential interaction between proton pump inhibitors (PPIs) and antiplatelet agents, particularly clopidogrel and aspirin 5, 6.
- Some studies have suggested that PPIs may reduce the antiplatelet effects of clopidogrel and/or aspirin, potentially leading to cardiovascular events 6.
- However, other studies have found no significant association between PPI use and adverse outcomes in patients receiving clopidogrel or ticagrelor 5.