Perioperative Management of Ticagrelor (Brilinta)
For patients receiving ticagrelor who are undergoing elective non-cardiac surgery, ticagrelor should be discontinued 3 to 5 days before surgery. 1
Timing of Ticagrelor Discontinuation
The timing of ticagrelor discontinuation depends on the type of surgery:
Non-cardiac Surgery
- Standard recommendation: Stop ticagrelor 3-5 days before elective non-cardiac surgery 1
- This timing allows sufficient recovery of platelet function in most patients while balancing thrombotic risk
Cardiac Surgery
- For CABG: Stop ticagrelor 3-5 days before surgery 1
- The American College of Cardiology Foundation/American Heart Association guidelines specifically state that ticagrelor should be discontinued for at least 5 days before elective CABG 1
Important Considerations
Bleeding Risk Assessment
- High bleeding risk procedures (neurosurgery, spinal surgery, posterior chamber eye surgery): Consider the longer end of the discontinuation window (5 days)
- Standard bleeding risk procedures: 3 days may be sufficient for many patients
Individual Variability
Research shows significant interindividual variability in platelet function recovery after ticagrelor discontinuation 2. While mean platelet aggregation reaches acceptable levels at 72 hours (3 days), approximately 25% of patients still have inadequate platelet function at this timepoint.
Stent Thrombosis Risk
For patients with recent coronary stent placement:
- If possible, delay elective surgery until completion of the mandatory dual antiplatelet therapy period
- For urgent/emergent surgery, the thrombotic risk of premature discontinuation must be carefully weighed against bleeding risk
Resumption of Therapy
- Resume ticagrelor within 24 hours after surgery if adequate hemostasis has been achieved 1
- For high bleeding risk procedures, resumption may be delayed based on postoperative bleeding assessment
Cautions and Pitfalls
Do not substitute heparin or LMWH for ticagrelor in the perioperative period, as these agents do not provide adequate protection against stent thrombosis 3
Platelet transfusions are not effective in reversing ticagrelor's antiplatelet effects, as demonstrated by research showing that ex vivo administration of platelet concentrate did not improve platelet aggregation after ticagrelor discontinuation 2
Bleeding complications increase significantly when ticagrelor is discontinued less than 72 hours before surgery, with research showing a 5-fold higher risk of major bleeding complications compared to control patients 4
By following these evidence-based recommendations for perioperative management of ticagrelor, clinicians can minimize bleeding complications while maintaining appropriate thrombotic protection for patients requiring surgery.