How long should Brilinta (ticagrelor) be held before surgery?

Timing of Ticagrelor (Brilinta) Discontinuation Before Surgery

Ticagrelor should be discontinued 3 to 5 days before elective non-cardiac surgery to minimize bleeding risk while maintaining adequate perioperative safety. 1

General Recommendations for Ticagrelor Discontinuation

• For elective non-cardiac surgery, ticagrelor should be stopped 3 to 5 days before the procedure rather than the traditional 7 to 10 days 1
• For patients undergoing coronary artery bypass graft (CABG) surgery specifically, ticagrelor should be discontinued at least 5 days before surgery 1
• Resumption of antiplatelet therapy should occur within 24 hours after surgery when hemostasis is achieved 1

Surgery-Specific Considerations

Cardiac Surgery

• For CABG surgery, ticagrelor should be discontinued for at least 5 days before elective procedures 1
• For urgent CABG, ticagrelor should be discontinued for at least 24 hours to reduce major bleeding risk 1
• Continuing ticagrelor within 72 hours of cardiac surgery is associated with significantly increased risk of major bleeding complications (48% vs 10%) 2

Non-Cardiac Surgery

• For elective non-cardiac surgery, the 3-5 day discontinuation window is recommended 1
• The recommendation may be modified based on individual patient circumstances, particularly surgery-related bleeding risk 1
• Platelet function testing is not routinely recommended to guide perioperative management 1

Risk Stratification

High Thrombotic Risk Patients

• For patients with recent coronary stent placement, elective surgery should be delayed when possible:
  • At least 6 weeks after bare metal stent placement 3
  • At least 6 months after drug-eluting stent placement 3
• For patients requiring surgery within 6-12 weeks of stent placement, either continuation of dual antiplatelet therapy or stopping one agent 7-10 days before surgery may be considered 1

Bleeding Risk Considerations

• Ticagrelor causes reversible inhibition of platelets but requires 3-5 days for adequate recovery of platelet function 4
• There is significant interindividual variability in platelet function recovery after ticagrelor discontinuation, with 25% of patients still having inadequate platelet function after 72 hours 4
• Ex vivo administration of platelet concentrates does not improve platelet aggregation after ticagrelor discontinuation 4

Important Caveats

• The decision to discontinue ticagrelor must balance bleeding risk against thrombotic risk 3
• For patients with high thrombotic risk requiring urgent surgery, cardiology consultation is recommended before discontinuing ticagrelor 3
• The timing of ticagrelor discontinuation should be individualized based on the specific procedure's bleeding risk and the patient's thrombotic risk 1, 2
• Ticagrelor discontinuation between 72-120 hours (3-5 days) before surgery shows no statistically significant increase in major bleeding complications compared to control patients 2