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

Timing of Ticagrelor (Brillinta) Discontinuation Before Surgery

For elective surgery, discontinue ticagrelor at least 5 days before the procedure; for urgent surgery, discontinue at least 24 hours before to reduce major bleeding complications. 1, 2

Elective Surgery Recommendations

Cardiac Surgery (CABG)

• Ticagrelor must be discontinued for at least 5 days before elective coronary artery bypass graft surgery to limit blood transfusions and bleeding complications 1, 2
• This 5-day window allows adequate platelet function recovery in most patients, though significant interindividual variability exists 3, 4
• After 72 hours (3 days) of discontinuation, approximately 75% of patients achieve acceptable platelet function recovery, but 25% remain at elevated bleeding risk 3

Non-Cardiac Surgery

• For elective non-cardiac surgery, discontinue ticagrelor 3-5 days before the procedure 2
• The American College of Chest Physicians specifically recommends this shorter 3-5 day window rather than the traditional 7-10 days for non-cardiac procedures 2
• The specific timing within this range should be based on the surgery's bleeding risk profile 2

Urgent Surgery Recommendations

For urgent CABG surgery, discontinue ticagrelor for at least 24 hours before the procedure to reduce major bleeding complications 1, 2

Important Caveats for Urgent Surgery

• When ticagrelor is discontinued 0-1 day before surgery, there is a substantially higher incidence of major bleeding complications (41% vs 21.7% with clopidogrel) 5
• Surgery performed within 72 hours of ticagrelor discontinuation carries significantly increased bleeding risk (48% major bleeding complications vs 10% in controls) 3
• If surgery can be delayed to 72-120 hours after discontinuation, bleeding risk approaches baseline levels (17% vs 15% in controls) 3

Platelet Function Recovery Timeline

The recovery of platelet function after ticagrelor discontinuation follows a predictable but variable pattern:

• 12-48 hours: Minimal platelet function recovery; highest bleeding risk 4
• 72 hours (3 days): Mean platelet aggregation reaches acceptable levels in 75% of patients, but substantial interindividual variability persists 3, 4
• 96-120 hours (4-5 days): Most patients achieve adequate platelet function recovery 1, 4

Key Clinical Pitfall

There is marked interindividual variability in platelet function recovery (range 4-88 aggregation units at 72 hours), meaning some patients require longer than 5 days for adequate recovery 4

Special Considerations for High-Risk Patients

Recent Stent Placement

• Delay elective surgery for at least 6 weeks after bare metal stent placement 2
• Delay elective surgery for at least 6 months after drug-eluting stent placement 2
• For surgery required within 6-12 weeks of stent placement, cardiology consultation is mandatory before discontinuing ticagrelor 2

Bridging Therapy

• Platelet transfusion does not effectively reverse ticagrelor's antiplatelet effects when given before adequate drug clearance 4
• Cangrelor (intravenous reversible P2Y12 inhibitor) can be used for bridging in high-risk patients, discontinued 1-6 hours before surgery 6

Postoperative Management

Resume ticagrelor within 24 hours after surgery once hemostasis is achieved 2

This recommendation balances the need to minimize thrombotic complications while ensuring adequate surgical hemostasis has been established 2