Platelet function recovery after ticagrelor withdrawal in patients awaiting urgent coronary surgery

• Published in: European journal of cardio-thoracic surgery Vol. 51; no. 4; pp. 633 - 637
• Main Authors: Hansson, Emma C., Malm, Carl Johan, Hesse, Camilla, Hornestam, Björn, Dellborg, Mikael, Rexius, Helena, Jeppsson, Anders
• Format: Journal Article
• Language: English
• Published: Germany Oxford University Press 01.04.2017
• Subjects: Adenosine - administration & dosage; Adenosine - adverse effects; Adenosine - analogs & derivatives; Adenosine - pharmacology; Aged; Blood Platelets - drug effects; Blood Platelets - physiology; Clinical Medicine; Coronary Artery Bypass - adverse effects; Coronary Artery Bypass - methods; Drug Administration Schedule; Female; Humans; Klinisk medicin; Male; Middle Aged; Platelet Aggregation - drug effects; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - adverse effects; Platelet Aggregation Inhibitors - pharmacology; Platelet Function Tests; Platelet Transfusion; Preoperative Care - methods; Preoperative Period; Prospective Studies; Purinergic P2Y Receptor Antagonists - administration & dosage; Purinergic P2Y Receptor Antagonists - adverse effects; Purinergic P2Y Receptor Antagonists - pharmacology; Withholding Treatment; Platelet aggregation inhibitors; Platelet transfusion; Cardiac surgery; Acute coronary syndrome; Platelet function test
• ISSN: 1010-7940; 1873-734X; 1873-734X
• DOI: 10.1093/ejcts/ezw373

Abstract OBJECTIVE: Dual antiplatelet therapy with ticagrelor and aspirin is associated with an increased risk of perioperative bleeding complications. Current guidelines recommend therefore discontinuation of ticagrelor 5 days before surgery to allow sufficient recovery of platelet function. It is not known how the time to recovery varies between individual patients after discontinuation of ticagrelor. METHODS: Twenty-five patients accepted for urgent coronary artery bypass surgery and treated with ticagrelor and aspirin were included in a prospective observational study. Platelet aggregation was evaluated with impedance aggregometry at five timepoints 12–96 h after discontinuation of ticagrelor. In a subset of patients (n = 15), we also tested the ex vivo efficacy of platelet concentrate supplementation on platelet aggregation. RESULTS: There was a gradual increase in mean adenosine diphosphate-induced platelet aggregation after discontinuation of ticagrelor. After 72 h, mean aggregation was 38 ±23 aggregation units (U), which is above a previously suggested cut-off of 22 U, when patients can be operated without increased bleeding risk. However, there was a large interindividual variability (range 4‒88 U at 72 h) and 6/24 patients (25%) had <22 U after 72 h. Ex vivo administration of platelet concentrate did not improve adenosine diphosphate-induced aggregation at any timepoint after ticagrelor discontinuation. CONCLUSIONS: Adenosine diphosphate-induced aggregation was acceptable after 72 h in the majority of patients but with a large interindividual variability. Due to the large variability, platelet function testing may prove to be a valuable tool in timing of surgery in patients with ongoing or recently stopped ticagrelor treatment. Adenosine diphosphate-induced aggregation was not improved by addition of platelet concentrate.