Top

Open Access 12-03-2025 | CABG | Original Paper

Dual antiplatelet pre-treatment with aspirin and ticagrelor in ACS patients undergoing unplanned aortocoronary bypass surgery

Authors: Christian Salbach, Mustafa Yildirim, Rebecca Gulba, Barbara Ruth Milles, Moritz Biener, Matthias Mueller-Hennessen, Hauke Hund, Norbert Frey, Evangelos Giannitsis

Published in: Clinical Research in Cardiology

Abstract

Background

Major bleedings following coronary artery bypass grafting (CABG) have significant implications on outcomes in acute coronary syndrome (ACS) patients. Owing fears of fatal bleedings in case of urgent CABG, current guidelines recommend a cessation of P2Y₁₂ receptor antagonists (P2Y₁₂-RA) before cardiac surgery and opt against routine pre-treatment with a P2Y₁₂-RA before coronary angiography (CA). However, sparse information exists outside randomized trials on the frequency of urgent CABG and the consequences of inappropriately long cessation of P2Y₁₂-RA treatment in patients presenting with ACS.

Methods

In this observational single-center study, ACS patients presenting to an emergency department requiring a CABG were recruited consecutively during a 2-year enrolment period. Baseline characteristics, CABG-related bleedings and all-cause mortality were collected from electronical medical records and related to the timing of CABG and P2Y₁₂-RA cessation.

Results

A total of 1,502 ACS patients were included, herein 102 (6.8%) underwent urgent CABG. The majority (76.5%) received a routine P2Y₁₂-RA pre-treatment predominantly ticagrelor in addition to low-dose aspirin before CA. 31 (30.4%) developed a CABG-related bleeding event. Bleeding probability was highest (HR: 4.77, 95%CI 2.20–10.37, p = 0.0001) when CABG was performed within 24 h after administration of dual anti-platelet therapy (DAPT). Despite high utilization rates of DAPT pre-treatment and high prevalence of CABG-related major bleedings, no fatal bleedings occurred.

Conclusions

Need of urgent CABG in ACS is infrequent and does not result in an excess of mortality. However, cessation of ticagrelor for at least 48 h before CABG is recommended to minimize rates of CABG-related bleedings.

Graphical Abstract

Available only for authorised users

Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Juni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B, Group ESCSD (2023) ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 44:3720–3826. https://doi.org/10.1093/eurheartj/ehad191CrossRefPubMed

Collet JP, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Juni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM, Group ESCSD (2021) 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 42:1289–1367. https://doi.org/10.1093/eurheartj/ehaa575CrossRefPubMed

Costa F, van Klaveren D, James S, Heg D, Raber L, Feres F, Pilgrim T, Hong MK, Kim HS, Colombo A, Steg PG, Zanchin T, Palmerini T, Wallentin L, Bhatt DL, Stone GW, Windecker S, Steyerberg EW, Valgimigli M, Investigators P-DS (2017) Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 389:1025–1034. https://doi.org/10.1016/S0140-6736(17)30397-5CrossRefPubMed

Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Van De Werf F, Avezum A, Goodman SG, Flather MD, Fox KA, Global Registry of Acute Coronary Events I (2003) Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 163:2345–2353. https://doi.org/10.1001/archinte.163.19.2345CrossRefPubMed

Gurbel PA, Bliden KP, Butler K, Tantry US, Gesheff T, Wei C, Teng R, Antonino MJ, Patil SB, Karunakaran A, Kereiakes DJ, Parris C, Purdy D, Wilson V, Ledley GS, Storey RF (2009) Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation 120:2577–2585. https://doi.org/10.1161/CIRCULATIONAHA.109.912550CrossRefPubMed

Held C, Asenblad N, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW, Nicolau JC, Scirica BM, Storey RF, Vintila M, Ycas J, Wallentin L (2011) Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol 57:672–684. https://doi.org/10.1016/j.jacc.2010.10.029CrossRefPubMed

Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA (2022) 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the american college of cardiology/american heart association joint committee on clinical practice guidelines. Circulation 145:e4–e17. https://doi.org/10.1161/CIR.0000000000001039CrossRefPubMed

Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation 123:2736–2747. https://doi.org/10.1161/CIRCULATIONAHA.110.009449CrossRefPubMed

Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF, ten Berg JM, Miller DL, Costigan TM, Goedicke J, Silvain J, Angioli P, Legutko J, Niethammer M, Motovska Z, Jakubowski JA, Cayla G, Visconti LO, Vicaut E, Widimsky P, Investigators A (2013) Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med 369:999–1010. https://doi.org/10.1056/NEJMoa1308075CrossRefPubMed

10.

Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Juni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO, Group ESCSD (2019) 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 40:87–165. https://doi.org/10.1093/eurheartj/ehy394CrossRefPubMed

11.

Post F, Gori T, Giannitsis E, Darius H, Baldus S, Hamm C, Hambrecht R, Hofmeister HM, Katus H, Perings S, Senges J, Munzel T (2015) Criteria of the German society of cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol 104:918–928. https://doi.org/10.1007/s00392-015-0888-2CrossRefPubMedPubMedCentral

12.

Schupke S, Neumann FJ, Menichelli M, Mayer K, Bernlochner I, Wohrle J, Richardt G, Liebetrau C, Witzenbichler B, Antoniucci D, Akin I, Bott-Flugel L, Fischer M, Landmesser U, Katus HA, Sibbing D, Seyfarth M, Janisch M, Boncompagni D, Hilz R, Rottbauer W, Okrojek R, Mollmann H, Hochholzer W, Migliorini A, Cassese S, Mollo P, Xhepa E, Kufner S, Strehle A, Leggewie S, Allali A, Ndrepepa G, Schuhlen H, Angiolillo DJ, Hamm CW, Hapfelmeier A, Tolg R, Trenk D, Schunkert H, Laugwitz KL, Kastrati A, Investigators I-RT (2019) Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med 381:1524–1534. https://doi.org/10.1056/NEJMoa1908973CrossRefPubMed

13.

Smith PK, Goodnough LT, Levy JH, Poston RS, Short MA, Weerakkody GJ, Lenarz LA (2012) Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis. J Am Coll Cardiol 60:388–396. https://doi.org/10.1016/j.jacc.2012.03.030CrossRefPubMedPubMedCentral

14.

Stoyanov KM, Hund H, Biener M, Gandowitz J, Riedle C, Lohr J, Mueller-Hennessen M, Vafaie M, Katus HA, Giannitsis E (2020) RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction. Eur Heart J Acute Cardiovasc Care 9:39–51. https://doi.org/10.1177/2048872619861911CrossRefPubMed

15.

Tarantini G, Mojoli M, Varbella F, Caporale R, Rigattieri S, Ando G, Cirillo P, Pierini S, Santarelli A, Sganzerla P, Cacciavillani L, Babuin L, De Cesare N, Limbruno U, Massoni A, Rognoni A, Pavan D, Belloni F, Cernetti C, Favero L, Saia F, Fovino LN, Masiero G, Roncon L, Gasparetto V, Ferlini M, Ronco F, Rossini R, Canova P, Trabattoni D, Russo A, Guiducci V, Penzo C, Tarantino F, Mauro C, Corrada E, Esposito G, Marchese A, Berti S, Martinato M, Azzolina D, Gregori D, Angiolillo DJ, Musumeci G, Investigators G, Italian Society of Interventional C (2020) Timing of Oral P2Y(12) Inhibitor Administration in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 76:2450–2459. https://doi.org/10.1016/j.jacc.2020.08.053CrossRefPubMed

16.

Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD, Morrow DA, White HD, Executive Group on behalf of the Joint European Society of Cardiology /American College of Cardiology /American Heart Association /World Heart Federation Task Force for the Universal Definition of Myocardial I (2018) Fourth Universal Definition of Myocardial Infarction (2018). Glob Heart 13:305–338. https://doi.org/10.1016/j.gheart.2018.08.004CrossRefPubMed

17.

Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Katus HA, Lindahl B, Morrow DA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasche P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S, Joint ESCAAHAWHFTFftUDoMI (2012) Third universal definition of myocardial infarction. Circulation 126:2020–2035. https://doi.org/10.1161/CIR.0b013e31826e1058CrossRefPubMed

18.

Varenhorst C, Alström U, Braun O, Storey RF, Mahaffey KW, Bertilsson M, Cannon CP, Scirica BM, Himmelmann A, James SK, Wallentin L, Held C (2014) Causes of mortality with ticagrelor compared with clopidogrel in acute coronary syndromes. Heart 100:1762–1769. https://doi.org/10.1136/heartjnl-2014-305619CrossRefPubMed

19.

Yildirim M, Mueller-Hennessen M, Milles BR, Biener M, Hund H, Frey N, Giannitsis E, Salbach C (2023) Real-world evidence on disparities on the initiation of Ticagrelor versus Prasugrel in patients with acute coronary syndrome. J Am Heart Assoc 12:ARTe030879Ne0308791161/JAHA.123.030879CrossRef

20.

Title: Dual antiplatelet pre-treatment with aspirin and ticagrelor in ACS patients undergoing unplanned aortocoronary bypass surgery
Authors: Christian Salbach
Mustafa Yildirim
Rebecca Gulba
Barbara Ruth Milles
Moritz Biener
Matthias Mueller-Hennessen
Hauke Hund
Norbert Frey
Evangelos Giannitsis
Publication date: 12-03-2025
Publisher: Springer Berlin Heidelberg
Keywords: CABG
CABG
Acute Coronary Syndrome
Ticagrelor
Clopidogrel
Prasugrel
Heart Surgery
Heart Surgery
Published in: Clinical Research in Cardiology
Print ISSN: 1861-0684
Electronic ISSN: 1861-0692
DOI: https://doi.org/10.1007/s00392-025-02629-0

Keynote series | Spotlight on menopause

Menopause
Video Series

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the systemic effects of menopause, so you can help patients in your clinics through the transition.

Prof. Martha Hickey

Dr. Claudia Barth

Dr. Samar El Khoudary

Developed by: Springer Medicine

Watch now

A quick guide to ECGs

Electrocardiography
Training Course

Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date.

PD Dr. Carsten W. Israel

Developed by: Springer Medizin

Start the cases