Discontinuation of P2Y12 antagonists before coronary bypass surgery: is 5 days really required?

This editorial refers to 'Coronary artery bypass graftingrelated bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study' † , by E.C. Hannson et al., on page 189.Bleeding in patients requiring urgent coronary artery bypass graft (CABG) surgery and dual antiplatelet therapy (DAPT) is a matter of concern and represents a major predictor of outcome.Prasugrel and ticagrelor are potent P2Y12 antagonists and are superior to clopidogrel in preventing major cardiovascular events in patients with acute coronary syndromes (ACS). 1,2Both agents are also associated with an increased rate of major bleeding. 3In the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel -Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI-38), the CABG-related bleeding rate was 4.7-fold higher with prasugrel in clopidogrel-naive patients, 1 whereas in the Platelet Inhibition and Patient Outcomes (PLATO) trial, no such increase was found with ticagrelor. 2 In the PLATO trial, patients assigned to ticagrelor undergoing CABG within 7 days of the last dose of study medication had a 50% relative reduction in mortality compared with clopidogrel, 4 and these deaths were related to cardiovascular, bleeding and infection events. 5The optimal discontinuation time of P2Y12 antagonists before CABG is still poorly defined.Current guidelines recommend a minimum of 5 days for ticagrelor and clopidogrel and a minimum of 7 days for prasugrel. 6This may be difficult to follow in the real world, and few data exist to show whether these delays are safe in terms of ischaemic complications and necessary in terms of a true reduction in relevant bleeding.Patients with non-ST-elevation myocardial ACS (NSTE-ACS) having complex multivessel coronary disease may require acute or urgent CABG within ,5 days.It is for these situations in particular that data are lacking to show the true bleeding incidence with shorter discontinuation periods of P2Y12 antagonists.In this issue of the Journal, Hansson et al. 7 report data from the SWEDEHEART registry on CABG-related bleeding complications in ACS patients on DAPT with either ticagrelor or clopidogrel.