CLINICAL OUTCOMES IN ACUTE CORONARY SYNDROME PATIENTS FOLLOWING CORONARY ARTERY BYPASS GRAFTING IN RELATION TO TIMING OF TICAGRELOR DISCONTINUATION: INSIGHTS FROM THE CAPITAL REGISTRY
Juan J. RussoNikita MalhotraF. RubensM BourqueJocelyn DupuisVincent ChanKuldeep SinghMarc RuelBenjamin HibbertAun‐Yeong ChongDerek So
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Abstract:
Patients with acute coronary syndromes (ACS) may require immediate or urgent coronary artery bypass grafting (CABG). Ticagrelor is a potent P2Y12 receptor antagonist increasingly used in the management of ACS. Although current guidelines suggest discontinuing ticagrelor at least 5 days prior to CABG, the optimal timing of CABG following ticagrelor administration has not been well established. We sought to assess in-hospital clinical outcomes in ACS patients following CABG in relation to the duration of ticagrelor discontinuation prior to surgery. We identified consecutive ACS patients who underwent CABG after having received ticagrelor. Patients were divided into 3 groups based on the timing of surgery after discontinuation of ticagrelor (<48 hours, 48 hours to <5 days, 5 or more days). We then compared clinical outcomes following CABG in relation to the duration of ticagrelor discontinuation. Clinical variables evaluated included postoperative bleeding, need for surgical reopening or blood transfusions, and length of stay in the intensive care unit (ICU). Of 336 patients undergoing CABG following ACS between January 2012 and December 2013, 38 received ticagrelor prior to CABG. Ticagrelor had been discontinued <48 hours prior to CABG in 14 patients (37%); 48 hours to <5 days in 14 (37%); and 5 days or more in 10 (26%). Baseline characteristics were comparable between ticagrelor discontinuation strata. CABG was deemed to be needed immediately in 21% of patients; within 24 hours in 11%; and on an urgent basis in the remaining 68%. Patients who underwent CABG <48 hours after ticagrelor discontinuation had more preoperative intra-aortic balloon pump use, and were more likely to require blood transfusions and a prolonged ICU stay (defined as >3 days). In addition, they had numerically higher, but non-statistically significant, rates of postoperative bleeding. Patients who underwent CABG 48 hours to <5 days after ticagrelor discontinuation had similar rates of postoperative bleeding and duration of ICU stay compared to patients who waited at least 5 days. A significant proportion of ACS patients who require CABG undergo surgery before the guideline recommended ticagrelor discontinuation period of 5 days. Patients who undergo CABG <48 hours after ticagrelor discontinuation are more like to require postoperative blood transfusions and a prolonged ICU stay. Notably, patients who undergo CABG 48 hours to <5 days after ticagrelor discontinuation have similar postoperative outcomes compared to patients who undergo CABG after 5 days of ticagrelor discontinuation. Large prospective series are needed to corroborate these findings.View Large Image Figure ViewerDownload (PPT)Keywords:
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Acute coronary syndrome plays a major role in the treatment of acute coronary syndrome. New agents have been developed and introduced into clinical practice while dual antiplattelet therapy has been limited with clopidogrel until recently. In this review we summarize the efficacy of ticagrelor, a new antiplatelet agent.
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Abstract Background Dual antiplatelet therapy is the current standard of care after acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). We intended to study the pattern of use of ticagrelor in patients with acute coronary syndrome undergoing PCI and the effect of switching over to other P2Y12 receptor inhibition on clinical outcomes. Results All patients aged > 18 years who had been admitted with acute coronary syndrome and had been provided ticagrelor as the second antiplatelet agent were included as study participants. The primary outcome of the study was the composite outcome of death, recurrent myocardial infarctions, re-intervention, and major bleeding. We studied 321 patients (54 female patients, 16.82%). The mean age of the patients was 56.65 ± 11.01 years. Ticagrelor was stopped in 76.7% on follow-up. It was stopped in 6.3%, 13.5%, 13.1%, 21.9%, and 45.1% of patients during the first month but after discharge, between first and third months, between 3 and 6 months, between 6 and 12 months, and after 12 months, respectively. In the majority of patients, ticagrelor was replaced by clopidogrel (97.9%). It was stopped according to the physician’s discretion in 79.3% of patients, whereas it was the cost of the drug that made the patient to get swapped to another agent in 18.6%. No difference in the primary composite outcome was observed between the groups where ticagrelor was continued post 12 months and ticagrelor was continued and ticagrelor was switched-over to another agent. Similarly, no difference in death, recurrent myocardial infarctions, re-interventions, or major bleeding manifestations was observed between the two groups. Conclusion In patients with acute coronary syndrome who undergo PCI, we observed that early discontinuation of ticagrelor and switching over to other P2Y12 inhibitors after discharge did not affect clinical outcomes.
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