Should anticoagulation be given to Non-ST-Elevation Myocardial Infarction (NSTEMI) patients with 3 vessel disease awaiting Coronary Artery Bypass Grafting (CABG)?

Anticoagulation Management for NSTEMI Patients with 3-Vessel Disease Awaiting CABG

Anticoagulation should be continued in NSTEMI patients with 3-vessel disease awaiting CABG, but P2Y12 inhibitors should be discontinued at least 5 days before surgery for clopidogrel and ticagrelor, and at least 7 days before surgery for prasugrel to minimize bleeding risk. 1

Anticoagulation Recommendations

Continue:

• Aspirin: Non-enteric-coated aspirin (81-325 mg daily) should be continued preoperatively and through CABG 1
• Anticoagulant therapy: Continue unfractionated heparin (UFH) until CABG 1

Discontinue:

• P2Y12 inhibitors:

  • Clopidogrel and ticagrelor: Discontinue at least 5 days before elective CABG 1
  • Prasugrel: Discontinue at least 7 days before elective CABG 1, 2
  • For urgent CABG: Discontinue P2Y12 inhibitors for at least 24 hours to reduce major bleeding 1

• GP IIb/IIIa inhibitors:

  • Short-acting IV GP IIb/IIIa inhibitors (eptifibatide or tirofiban): Discontinue at least 2-4 hours before surgery 1
  • Abciximab: Discontinue at least 12 hours before surgery 1

Timing Considerations

The timing of CABG in NSTEMI patients requires balancing bleeding risk against the benefits of not delaying surgery:

• Approximately one-third of NSTEMI patients undergo CABG within 48 hours of hospital admission 1
• Median time to CABG after admission is 73 hours (interquartile range: 42-122 hours) 1
• In-hospital mortality for NSTEMI patients undergoing CABG is approximately 3.7% 1

Bleeding Risk Assessment

The risk of bleeding complications varies based on timing of P2Y12 inhibitor discontinuation:

• <24 hours after discontinuation: Significantly increased risk of major bleeding complications 1
• 1-4 days after discontinuation: Life-threatening bleeding not significantly increased, but higher likelihood of blood transfusions 1
• ≥5 days after discontinuation: Optimal timing to minimize bleeding risk 1

Special Considerations

• For patients with high ischemic risk and low bleeding risk, it may be reasonable to perform CABG less than 5 days after clopidogrel or ticagrelor discontinuation and less than 7 days after prasugrel discontinuation (Class IIb recommendation) 1
• Prasugrel is associated with higher incidence of CABG-related major bleeding compared to clopidogrel 1, 2
• Despite pharmacokinetic studies showing more rapid recovery of platelet function with ticagrelor, this did not translate to lower bleeding risk or reduced transfusion requirements when CABG was performed early (<5 days after discontinuation) 1

Pitfalls to Avoid

1. Do not discontinue aspirin before CABG as it reduces operative morbidity and mortality with only modest increase in bleeding risk 1, 3

2. Do not use prasugrel in patients with prior history of stroke or TIA as it is potentially harmful (Class III: Harm recommendation) 1, 2

3. Do not delay anticoagulation therapy in NSTEMI patients as it should be added to antiplatelet therapy as soon as possible after presentation 1

4. Avoid prasugrel in patients likely to undergo urgent CABG 2

By following these evidence-based recommendations, you can optimize the management of NSTEMI patients with 3-vessel disease awaiting CABG, balancing the need for continued antithrombotic protection while minimizing perioperative bleeding risk.