Timing of Ticagrelor (Brilinta) Discontinuation Before Surgery
For elective coronary artery bypass graft (CABG) surgery, ticagrelor should be discontinued for at least 5 days before surgery to minimize bleeding risk while maintaining adequate perioperative safety. 1, 2
Timing Guidelines Based on Surgery Type
Cardiac Surgery
- For elective CABG surgery: Discontinue ticagrelor at least 5 days before surgery 1, 2
- For urgent CABG surgery: Discontinue ticagrelor for at least 24 hours before surgery to reduce major bleeding complications 1
Non-Cardiac Surgery
- For elective non-cardiac surgery: Discontinue ticagrelor 3-5 days before the procedure 2
- For emergency surgery: Proceed without delay, with awareness of increased bleeding risk 3
Rationale for Timing Recommendations
- Ticagrelor has a reversible mechanism of action but still requires sufficient time for platelet function recovery 4
- Platelet function typically recovers gradually after ticagrelor discontinuation, with most patients reaching acceptable levels after 72 hours 4
- However, there is significant interindividual variability in recovery time, with approximately 25% of patients still having inadequate platelet function at 72 hours 4
Important Considerations
- The decision to discontinue ticagrelor must balance bleeding risk against thrombotic risk 2
- For patients with high thrombotic risk requiring urgent surgery, cardiology consultation is recommended 2
- Platelet transfusion has limited efficacy in reversing ticagrelor's effects, as demonstrated by ex vivo studies showing no significant improvement in platelet function with platelet concentrate administration 4
Special Populations
- For patients with recent coronary stent placement, elective surgery should ideally be delayed when possible 2
- For patients requiring surgery within 6-12 weeks of stent placement, careful risk assessment is needed 2
Resumption of Therapy
- Antiplatelet therapy should be resumed within 24 hours after surgery when adequate hemostasis is achieved 2
- If aspirin was not initiated preoperatively, it should be started within 6 hours postoperatively for CABG patients 1
Potential Pitfalls
- Waiting longer than necessary (traditional 7-10 days) may increase thrombotic risk unnecessarily 2
- Not waiting long enough increases bleeding risk, particularly in surgeries involving closed spaces (intracranial, spinal, posterior chamber of eye) 5
- Replacing ticagrelor with heparin or low-molecular-weight heparin does not provide adequate protection against stent thrombosis 5