Ischemic and bleeding outcomes after coronary artery bypass grafting among patients initially treated with a P2Y receptor antagonist for acute coronary syndromes: Insights on timing of discontinuation of ticagrelor and clopidogrel prior to surgery.

BACKGROUND

Clinical outcomes in acute coronary syndrome patients treated with P2Y inhibitors who require urgent coronary artery bypass grafting (CABG) have not been well studied.

METHODS

We examined clinical outcomes in acute coronary syndrome patients in relation to the timing of CABG following P2Y inhibitor discontinuation (<72 h, 72 h to five days, >5 days). The primary ischemic outcome was a composite of death, reinfarction, need for revascularization, or stroke. The primary safety outcome was bleeding of at least moderate severity as defined by a Universal Definition of Perioperative Bleeding class ≥2.

RESULTS

Among 508 patients (95 ticagrelor, 413 clopidogrel), the timing of CABG following P2Y inhibitor discontinuation was <72 h in 32.1%, 72 h to five days in 23.2% and >5 days in 44.7%. Compared with CABG within 72 h, CABG 72 h to five days (adjusted odds ratio (OR) 0.35; 95% confidence interval (CI) 0.14-0.85; =0.02) but not >5 days (adjusted OR 0.62; 95% CI 0.33-1.16; =0.14) after P2Y inhibitor discontinuation was associated with lower odds of the primary ischemic outcome. Compared with CABG within 72 h, CABG 72 h to five days (adjusted OR 0.38; 95% CI 0.22-0.66; =0.001) and >5 days (adjusted OR 0.33; 95% CI 0.20-0.53; <0.001) after P2Y inhibitor discontinuation were associated with lower rates of Universal Definition of Perioperative Bleeding class ≥2 bleeding.

CONCLUSIONS

CABG within 72 h after P2Y inhibitor discontinuation is associated with excess ischemia and bleeding. The rates of ischemic and bleeding events were comparable in patients undergoing CABG 72 h to five days compared with >5 days after P2Y inhibitor discontinuation.