Time from stopping blood thinner to bypass surgery may be shortened for select patients

Research Highlights:

  • The medication ticagrelor is a common anti-platelet medication prescribed to prevent blood clotting after a heart attack. Because ticagrelor is a blood thinner, it should be stopped prior to surgery due to the risk of bleeding.
  • Notably, 10% of patients with heart attacks require coronary artery bypass surgery. Current American Heart Association guidelines recommend people who take ticagrelor and need bypass surgery should stop taking the medicine 5-7 days before surgery.
  • A small, randomized study of people who had heart attacks shows there is no increased bleeding risk when stopping ticagrelor 2-3 days before bypass surgery.
  • Researchers say this may enable patients to go to bypass surgery sooner and may also decrease hospital length of stay.

Embargoed until 9:03 a.m. CT/10:03 a.m. ET Saturday, Nov. 13, 2021

(NewMediaWire) – November 13, 2021 – DALLAS – People who are on the antiplatelet medication ticagrelor and need coronary artery bypass surgery may be able to safely have the procedure after waiting less time than typically recommended after the medication is stopped, according to late-breaking research presented today at the American Heart Association’s Scientific Sessions 2021. The meeting is fully virtual, Saturday, November 13-Monday, November 15, 2021, and is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care professionals worldwide.

“We discovered no significant increase in bleeding when people had bypass surgery after 2-3 days of discontinuing ticagrelor,” said lead study author Derek So, M.D, a cardiologist at the University of Ottawa Heart Institute and a professor at the University of Ottawa in Canada. “These findings may be surprising based on the assumption that the presence of a strong blood thinner should predispose people to severe bleeding.”

Ticagrelor is a common medication prescribed to people who have had a heart attack or unstable angina to help prevent future cardiac events. It works by preventing blood platelets from sticking together, thus inhibiting blood clots from forming. Because the medication thins the blood and prevents clotting, there is a risk of severe bleeding during surgery.

Current guidelines in the U.S. and Canada recommend that people taking ticagrelor who need coronary artery bypass surgery should stop taking the medication 5-7 days before the surgery to reduce their risk of massive bleeding. A potential concern, however, is the risk of a recurrent heart attack or angina pains during the 5-7-day window of not taking the medicine.

To evaluate if a shorter waiting time for surgery after stopping ticagrelor is safe, the “Reassessment of Anti-Platelet Therapy Using InDividualized Strategies – Ticagrelor in Patients With Acute Coronary Syndromes Treated by Coronary Artery Bypass Graft Surgery (RAPID CABG)” trial assessed bleeding after bypass surgery in people at two centers in Canada. The study investigators randomly assigned 143 people who previously had suffered heart attacks, had received ticagrelor and required bypass surgery into two groups – one for earlier surgery after stopping ticagrelor and the other for surgery after the standard wait time.

A total of 72 people (average age of 64 years, 80.6% male) were in the early bypass surgery group and had surgery 2-3 days after stopping ticagrelor, and 71 people (average age of 65.5 years, 83.1% male) were in the delayed surgery group, following current standard of care of stopping ticagrelor 5-7 days before surgery. The people in both groups had similar baseline characteristics, including age and percentages of coexisting health conditions.

Study researchers gauged the number of people who had severe or massive perioperative bleeding during the early post-surgical period, as defined by the universal definition of perioperative bleeding (UDPB). Severe or massive bleeding defined by UDPB includes massive blood transfusions of >5 units of red cells or plasma within 24 hours of surgical closure, chest tube drainage of over 1000 mL in the first 12 hours and re-operation for bleeding. The investigators also compared length of stay in the hospital and rates of episodes of angina, recurrent heart attack, stroke and death among the two groups.

The results found:

  • Bypass surgery in the early surgery group (after 2-3 days of stopping ticagrelor) showed no increased risk of early post-surgical bleeding, and rates of bleeding were similar between the two groups.
  • The rate of severe or massive perioperative bleeding (using the universal definition of perioperative bleeding) was 4.6% in the early surgery group and 5.2% in the delayed group. For clinical reasons, some people in the delayed surgery group had to have CABG surgery sooner than the planned date; 9% experienced recurrent angina (chest pains), recurrent heart attack and ventricular arrhythmias (abnormal rhythms which may be due to the blockages) that prompted earlier surgery.
  • In contrast, no one in the early surgery group had to have surgery earlier than two days after they stopped taking ticagrelor.
  • The average length of hospital stay was reduced by 3 days among the participants in the early surgery group compared to the delayed surgery group.

“Research such as this, with people randomly allocated to early vs. delayed surgery, is integral to assure cardiologists and surgeons that early surgery is safe, especially since it conflicts with the present guidelines for people who are taking ticagrelor,” So said. “Furthermore, although our study was not large enough to evaluate whether early surgery protects people from suffering early recurrent heart attacks or angina, it opens this hypothesis and may prompt future research in the area.”

Co-authors are Marie Lordkipanidze, Ph.D., B.Pharm.; Fraser Rubens, M.D., M.Sc.; Marc Ruel, M.D., M.P.H.; Louis P Perrault, M.D., Ph.D.; Aun Yeong Chong, M.D.; George Wells, Ph.D.; and Jean-Francois Tanguay, M.D., FAHA. Authors’ disclosures are listed in the abstract.

The study was funded by the Canadian Institutes of Health Research (CIHR).

Additional Resources:

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

The American Heart Association’s Scientific Sessions 2021 is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science for health care professionals worldwide. The 3-day meeting will feature more than 500 sessions focused on breakthrough cardiovascular basic, clinical and population science updates in a fully virtual experience Saturday, November 13 through Monday, November 15, 2021. Thousands of leading physicians, scientists, cardiologists, advanced practice nurses and allied health care professionals from around the world will convene virtually to participate in basic, clinical and population science presentations, discussions and curricula that can shape the future of cardiovascular science and medicine, including prevention and quality improvement. During the three-day meeting, attendees receive exclusive access to more than 4,000 original research presentations and can earn Continuing Medical Education (CME), Continuing Education (CE) or Maintenance of Certification (MOC) credits for educational sessions. Engage in Scientific Sessions 2021 on social media via #AHA21.

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