RAPID CABG: Ticagrelor Can Be Discontinued 2-3 Days Prior to CABG without Increasing Bleeding Risk

Derek So, MD

Results of the RAPID CABG study presented at the American Heart Association 2021 Scientific Sessions provide insight into the timing of ticagrelor discontinuation on bleeding risk among patients requiring coronary artery bypass grafting (CABG).

Although guidelines recommend stopping ticagrelor at least 3 or 5 days prior to surgery, results from the 6-month follow-up of RAPID CABG indicate patients could discontinue treatment 2-3 days prior to surgery without increasing risk of early post-surgical bleeding and could also reduce the average length of hospital stay.

“We discovered no significant increase in bleeding when people had bypass surgery after 2-3 days of discontinuing ticagrelor,” said lead study author Derek So, MD, a cardiologist at the University of Ottawa Heart Institute and a professor at the University of Ottawa in Canada, in a statement from the AHA. “These findings may be surprising based on the assumption that the presence of a strong blood thinner should predispose people to severe bleeding.”

So and a team of colleagues conducted the RAPID CABG trial with the aim of providing insight into the ideal window for discontinuing ticagrelor use as a result of guideline recommendations for timing of discontinuation creating a dilemma for clinicians concerned about the risk of recurrent events before surgery. Conducted in 2 centers in Canada, the RAPID CABG randomized a population of 143 patients with a history of acute coronary syndrome to early CABG surgery or standard CABG.

For inclusion in the analysis, patients needed to be at least 18 years of age, and have undergone angiography for unstable angina, non-ST-elevation myocardial infarction, or medically treated STEMI. Patients were excluded if they required stunting for culprit lesions, requiring urgent surgery, or required valve surgery.

The primary outcome of the trial was the incidence of class 3 or 4 perioperative bleeding. Perioperative bleeding was defined as a compsite of massive transfusion, reoperation for bleeding and chest tube drainage exceeding 1000 mL in 12 hours. Secondary outcomes of interest were bleeding outcomes, including BARC type 3, TIMI CABG-related bleeding and cardiac tamponade, and ischemic outcomes, including cardiovascular death, stroke, myocardial infarction, refractory ischemia, and unplanned revascularization.

The early surgery and delayed surgery group had similar baseline characteristics. The early group had a mean age of 64 years and 80.6% were men. The delayed surgery group had a mean age of 65.5 years and 83.1% were male.

Upon analysis, 6-month results of the trial suggested the rate of severe or massive perioperative bleeding was 4.6% among the early surgery group and 5.2% among the delayed group. When assessing different forms of bleeding, there were no statistically significant differences in TIMI CABG, BARC type 4, or BARC type 5 bleeding between the study groups. Investigators pointed out 9% of patients in the delayed surgery group required surgery sooner than the planned date due to recurrent angina, recurrent heart attack, or ventricular arrhythmias. No patients randomized to the early surgery arm required intervention earlier than 2 days after discontinuing ticagrelor.

When assessing secondary outcomes, results suggested a MACE outcome occurred within the first 6 months following surgery among 5.6% of those randomized to early CABG compared to 13.0% of those randomized to delayed surgery. Additionally, the median length of stay from randomization to discharge was 9 (IQR, 7-13) days among the early surgery group compared to 12 (IQR, 10-15) days.

“Research such as this, with people randomly allocated to early vs. 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 said. “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.”

This study, “A Randomized Study Of Early Versus Standard Coronary Artery Bypass Surgery Among Patients Presenting With Acute Coronary Syndromes Treated With Ticagrelor (RAPID CABG),” was presented at AHA 2021.