What is the recommended perioperative management of antiplatelet therapy for patients undergoing Coronary Artery Bypass Grafting (CABG) who have received a loading dose of ticagrelor (P2Y12 inhibitor)?

Perioperative Management of Ticagrelor in CABG Patients

For patients undergoing CABG who have received a ticagrelor loading dose, discontinue ticagrelor 3-5 days before elective surgery, continue aspirin perioperatively, and resume both agents within 24 hours postoperatively unless contraindicated by bleeding complications. 1

Preoperative Management

Timing of Ticagrelor Discontinuation

• Stop ticagrelor 3-5 days (72-120 hours) before elective CABG to minimize major bleeding complications while balancing thrombotic risk 1
• The 3-5 day window represents a significant departure from older recommendations of 5-7 days, based on ticagrelor's more rapid platelet function recovery compared to clopidogrel 1, 2
• For urgent CABG, discontinue ticagrelor at least 24 hours before surgery to reduce major bleeding risk, though surgery may proceed if clinically necessary 1
• Discontinuation less than 72 hours before surgery is associated with substantially increased major bleeding complications (48% vs 10% when stopped >72 hours) 3

Evidence Supporting Shorter Discontinuation

The most compelling recent evidence comes from a Swedish nationwide registry study showing that ticagrelor discontinued 72-120 hours before CABG had no significant difference in major bleeding compared to >120 hours (odds ratio 0.93,95% CI 0.53-1.64), unlike clopidogrel which required the full 5 days 2. A European multicenter study confirmed that ticagrelor stopped ≥3 days before surgery resulted in only 2.7% major bleeding versus 16.0% when stopped 0-2 days prior 4.

Aspirin Management

• Continue aspirin (81-325 mg daily) throughout the perioperative period without interruption 1
• Preoperative aspirin reduces operative morbidity and mortality with only modest bleeding increase 1
• Non-enteric-coated aspirin should be administered preoperatively 1

Critical Caveat: Individual Variability

A major pitfall is assuming all patients recover platelet function uniformly. Despite mean platelet aggregation reaching acceptable levels at 72 hours post-discontinuation, 25% of patients remain below safe thresholds even after 3 days 5. This substantial interindividual variability (range 4-88 aggregation units at 72 hours) suggests that:

• Platelet function testing may be considered in patients undergoing CABG who recently received ticagrelor, particularly when surgery timing is critical 1
• Testing is not routinely recommended but has potential benefit in this specific high-risk scenario with moderate implementation costs 1

Postoperative Management

Resumption of Antiplatelet Therapy

• Resume both aspirin and ticagrelor within 24 hours after CABG to reduce subsequent cardiovascular events 1
• Early resumption (≤24 hours) is preferred over delayed resumption (≥24 hours) 1
• Delay resumption if post-CABG thrombocytopenia develops (platelet count <50,000/μL), which typically occurs with on-pump surgery 1

Duration of Dual Antiplatelet Therapy

• Continue dual antiplatelet therapy (aspirin + ticagrelor) for 12 months in patients with recent acute coronary syndrome or coronary stent placement 1, 6
• This 12-month duration reduces subsequent cardiovascular events and graft occlusion 6
• Aspirin should be continued indefinitely after the 12-month DAPT period 1

Special Considerations for Recent Stent Placement

If the patient has a coronary stent placed within 6-12 weeks before CABG:

• The decision to continue or stop ticagrelor must weigh bleeding risk against stent thrombosis risk (which carries up to 50% mortality) 1
• Consider continuing both antiplatelet agents or stopping only one agent, depending on: 1
  • Timing of stent placement (closer to 6 vs 12 weeks)
  • Type of stent (drug-eluting vs bare-metal)
  • Stent location and number
  • Individual bleeding risk of the surgery

Practical Algorithm

For Elective CABG:

1. Stop ticagrelor 3-5 days before surgery 1
2. Continue aspirin throughout 1
3. Consider platelet function testing if surgery must occur <3 days after discontinuation 1
4. Resume both agents within 24 hours postoperatively 1

For Urgent CABG:

1. Stop ticagrelor ≥24 hours before surgery if possible 1
2. Continue aspirin 1
3. Proceed with surgery even if <24 hours if clinically necessary (Class IIb recommendation) 1
4. Resume both agents within 24 hours postoperatively unless bleeding complications occur 1

Key Pitfall to Avoid

Do not routinely wait 5-7 days for ticagrelor washout as you would for clopidogrel or prasugrel. The pharmacokinetic profile of ticagrelor allows for shorter discontinuation (3-5 days vs 5 days for clopidogrel and 7 days for prasugrel), and unnecessarily prolonged delays increase thrombotic risk without additional bleeding benefit 1, 2.