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

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 P2Y receptor antagonists (P2Y-RA) before cardiac surgery and opt against routine pre-treatment with a P2Y-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 P2Y-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 P2Y-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 P2Y-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.