Ticagrelor Discontinuation Before Surgery
Stop ticagrelor 3 to 5 days before elective non-cardiac surgery. 1
Standard Discontinuation Timeline
For most elective non-cardiac surgeries, discontinue ticagrelor 3 to 5 days preoperatively rather than the older recommendation of 7 to 10 days. 1 This shorter window is based on ticagrelor's reversible P2Y12 receptor binding and 12-hour half-life, which allows for adequate platelet function recovery within this timeframe. 2, 3
Surgery-Specific Recommendations
For CABG surgery specifically, stop ticagrelor 3 to 5 days before the procedure. 1, 3 The American College of Chest Physicians explicitly recommends this 3-5 day window for pre-operative P2Y12 interruption prior to CABG. 1
For procedures with extremely high bleeding risk (intracranial surgery, spinal canal surgery, posterior chamber eye surgery), consider extending to the full 5-day discontinuation period. 1
Evidence Supporting the 3-Day Minimum
Research demonstrates that discontinuation 3 days (72 hours) before surgery does not increase major bleeding complications compared to 5+ days. 4 A Swedish nationwide study of 1,266 ticagrelor-treated patients undergoing CABG found no significant difference in major bleeding when ticagrelor was stopped 72-120 hours versus >120 hours before surgery (OR 0.93,95% CI 0.53-1.64, P=0.80). 4
However, discontinuation <72 hours (less than 3 days) significantly increases bleeding risk. 5 In the European E-CABG registry, patients who stopped ticagrelor 0-2 days before surgery had a 16.0% major bleeding rate versus only 2.7% when stopped ≥3 days preoperatively (p=0.003). 5
Critical Caveat on Individual Variability
Despite mean platelet function recovery at 72 hours, approximately 25% of patients still have inadequate platelet function at this timepoint. 6 A prospective study showed that while mean ADP-induced platelet aggregation reached acceptable levels (>22 U) at 72 hours, there was large interindividual variability (range 4-88 U), with 6 of 24 patients (25%) remaining below the safe threshold. 6
High-Risk Scenarios Requiring Modified Approach
For patients with recent coronary stents (within 6-12 weeks), either continue both antiplatelet agents or stop only one agent rather than stopping both. 1 The decision depends on balancing surgical bleeding risk against acute coronary syndrome/stent thrombosis risk. 1
For urgent/emergency surgery where ticagrelor cannot be stopped, proceed with surgery while implementing aggressive hemostatic measures, as the thrombotic risk of delaying surgery typically outweighs bleeding risk. 2, 3
Resumption After Surgery
Resume ticagrelor within 24 hours postoperatively if there are no active bleeding complications. 1, 2 For patients who undergo PCI during the procedure, restart ticagrelor as soon as hemostasis is secure. 2, 3
Common Pitfalls to Avoid
Do not use platelet transfusions to reverse ticagrelor's effects, as ticagrelor remains in plasma and immediately inhibits transfused platelets. 3 Research confirms that ex vivo platelet concentrate supplementation does not improve ADP-induced aggregation at any timepoint after ticagrelor discontinuation. 6
Do not bridge with low-molecular-weight heparin when stopping ticagrelor for surgery in high stent thrombosis risk patients, as this does not prevent stent thrombosis and increases bleeding risk. 3
Do not routinely use platelet function testing to guide timing, though it may have value in select high-risk cases (e.g., patients likely to need CABG who recently started ticagrelor). 1