Can coronary artery bypass grafting (CABG) be performed in a patient taking aspirin and ticagrelor?

CABG Can Proceed with Aspirin Continued; Ticagrelor Should Be Stopped

Yes, CABG can proceed in patients on aspirin and ticagrelor, but the timing and management differ for each drug: aspirin should be continued perioperatively, while ticagrelor must be discontinued before surgery with timing based on urgency.

Aspirin Management

Continue aspirin throughout the perioperative period 1, 2, 3. Aspirin (100-325 mg daily) should be:

• Administered preoperatively and maintained until surgery
• Restarted within 6 hours postoperatively if not given preoperatively 4
• Continued indefinitely after CABG to improve saphenous vein graft patency and reduce mortality, MI, stroke, and other cardiovascular events 4

The evidence strongly supports uninterrupted aspirin therapy. While older meta-analyses suggested modest bleeding increases, the 2018 ATACAS trial (2,100 patients) found aspirin caused neither increased bleeding/reoperation nor reduced thrombotic complications 5. The graft patency benefits are well-established, particularly for saphenous vein grafts in the first postoperative year 4.

Ticagrelor Management

For Elective CABG

Discontinue ticagrelor 3-5 days before surgery 1, 2, 4. The most recent 2025 ACC/AHA guidelines recommend interruption for 3-5 days before elective CABG 1, while the 2011 guidelines recommended at least 5 days 2, 4.

For Urgent CABG

Discontinue ticagrelor for at least 24 hours ideally, though proceeding earlier than 5 days may be reasonable 1, 2, 4. The 2025 guidelines state interruption for at least 24 hours (ideally) with proceeding earlier than 5 days being reasonable 1.

Key Evidence on Ticagrelor and Bleeding

The PLATO trial data is critical here: Among 1,261 patients undergoing CABG within 7 days of last drug dose, bleeding rates were similar between ticagrelor (59.3%) and clopidogrel (57.6%), as were transfusion requirements (55.7% vs 56.5%) 4. Importantly, no difference in bleeding occurred even when CABG was performed 1,2, or 3 days after discontinuation 4.

However, more recent real-world data shows nuance:

• A 2016 propensity-matched study found continuing ticagrelor up to surgery or stopping <2 days before increased platelet transfusion (22.7% vs 6.4%) and severe bleeding (18.2% vs 5.9%) 6
• When stopped ≥2 days before surgery, platelet transfusion rates were still higher with ticagrelor (12.4% vs 3.6%) but bleeding severity was similar 6

Most Recent Outcome Data (2025)

The 2025 TACSI trial (2,201 patients) compared ticagrelor plus aspirin versus aspirin alone for 1 year after CABG for acute coronary syndrome 7. Critical findings:

• No reduction in MACCE (death, MI, stroke, repeat revascularization): 4.8% vs 4.6%, HR 1.06 (95% CI 0.72-1.56)
• Increased net adverse clinical events: 9.1% vs 6.4%, HR 1.45 (95% CI 1.07-1.97)
• Significantly increased major bleeding: 4.9% vs 2.0%, HR 2.50 (95% CI 1.52-4.11)

This challenges the benefit of adding ticagrelor to aspirin post-CABG, even in ACS patients.

Practical Algorithm

Elective CABG:

1. Continue aspirin throughout
2. Stop ticagrelor 3-5 days before surgery 1
3. Resume ticagrelor 24-72 hours postoperatively when bleeding risk acceptable 1

Urgent CABG (cannot wait 3-5 days):

1. Continue aspirin throughout
2. Stop ticagrelor at least 24 hours before if possible 1, 2
3. Accept higher platelet transfusion risk if surgery needed sooner
4. Consider platelet function testing if available to guide timing 8, 5

Emergency CABG (immediate surgery needed):

1. Continue aspirin
2. Proceed with surgery on ticagrelor if life-threatening situation
3. Prepare for increased bleeding/transfusion requirements
4. Have platelets available

Critical Caveats

• The 2025 TACSI trial suggests aspirin alone may be superior to dual therapy post-CABG 7, contradicting older assumptions about DAPT benefits
• Ticagrelor's theoretical advantage of faster platelet recovery (reversible binding) does not translate to reduced bleeding versus clopidogrel in practice 4
• The European 2024 guidelines recommend stopping ticagrelor ≥3 days before CABG 3, slightly shorter than the 3-5 day window in 2025 ACC/AHA guidelines 1
• Never stop aspirin - the thrombotic risk outweighs bleeding concerns 2, 3, 5