AHA 2021: RAPID CABG trial finds in favour of bypass surgery sooner after ticagrelor cessation

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Coronary artery bypass graft sugery (CABG) between two and three days after ticagrelor cessation was found to be non-inferior in incurring severe or massive perioperative bleeding compared to waiting between five and seven days prior to the procedure, per current guidelines.

This is according to findings of the RAPID CABG study, presented during a late-breaking science session at the American Heart Association’s Scientific Sessions 2021 (AHA 2021; 13–15 November; virtual) by Derek So (University of Ottawa Heart Institute and a professor at the University of Ottawa, Ottawa, Canada. The findings could influence future guidelines and prompt a reduced waiting time prior to CABG surgery, the study’s authors claim.

According to So, 10% of patients with acute coronary syndromes (ACS) require CABG, among whom perioperative bleeding is a major concern. In the PLATO trial, which assessed the antiplatelet medication ticagrelor versus clopidogrel in patients with acute coronary syndromes, patients undergoing CABG one day or less after ticagrelor were found to have high mortality.

Current guidelines recommend that people taking ticagrelor requiring CABG should stop taking the medication between five and seven 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 window of time during which they are not not taking the medicine.

To evaluate if a shorter waiting time for surgery after stopping ticagrelor is safe, the RAPID CABG study assessed bleeding after bypass surgery in people at two centres 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 two to three 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 five to seven 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 1,000mL in the first 12 hours and reoperation 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 investigators found that bypass surgery in the early surgery group (after two to three 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.

“We discovered no significant increase in bleeding when people had bypass surgery after two to three days of discontinuing ticagrelor,” said So. These findings may be surprising based on the assumption that the presence of a strong blood thinner should predispose people to severe bleeding, he commented.

“Research such as this, with people randomly allocated to early versus 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 added. “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.”


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