Management of Ticagrelor (Brilinta) Before Heart Catheterization
Ticagrelor should be discontinued 3-5 days before elective heart catheterization if there is concern for bleeding risk, but can be continued if the procedure is urgent or the thrombotic risk outweighs bleeding concerns. 1
Discontinuation Recommendations for Ticagrelor
- Ticagrelor should be discontinued 3-5 days before elective procedures with significant bleeding risk, including heart catheterization 1
- This is shorter than the traditional 7-10 day discontinuation window that was previously recommended for antiplatelet agents 1
- The recommendation is based on ticagrelor's reversible binding properties and shorter half-life (12 hours) compared to other P2Y12 inhibitors 1, 2
Evidence Supporting Shorter Discontinuation Times
- Recent studies show that discontinuing ticagrelor 72-120 hours (3-5 days) before surgery does not significantly increase bleeding risk compared to longer discontinuation periods 3, 4
- In contrast to ticagrelor, clopidogrel requires a longer discontinuation period (5 days) due to its irreversible binding mechanism 1
- A Swedish registry study demonstrated that ticagrelor discontinuation 3 days before cardiac surgery did not increase major bleeding complications compared to 5+ days, while clopidogrel did show increased bleeding when discontinued at 3 days versus 5+ days 3
Risk Stratification Approach
- For patients at high thrombotic risk (recent stent placement within 6-12 weeks, recent acute coronary syndrome), the decision to discontinue ticagrelor should balance thrombotic versus bleeding risks 1
- For low thrombotic risk patients, discontinuation 3-5 days before the procedure is appropriate 1
- Heart catheterization without planned intervention may be performed with continued ticagrelor if urgently needed 1
Special Considerations
- There is significant interindividual variability in platelet function recovery after ticagrelor discontinuation, with some patients requiring longer than 72 hours to achieve adequate platelet function 5, 1
- If the heart catheterization is likely to lead to coronary artery bypass grafting (CABG), ticagrelor should be discontinued 3-5 days before the procedure to minimize bleeding risk 1
- For diagnostic heart catheterization without anticipated intervention, the bleeding risk is lower and may not require discontinuation in urgent cases 1
Resumption After Procedure
- Antiplatelet therapy should be resumed within 24 hours after the procedure if there are no bleeding complications 1
- For patients who undergo PCI during catheterization, ticagrelor should be restarted as soon as possible 1
Conclusion
For elective heart catheterization, discontinuing ticagrelor 3-5 days before the procedure is recommended to minimize bleeding risk. However, in urgent cases or when thrombotic risk is high, proceeding with the procedure while on ticagrelor may be appropriate based on individual risk assessment.