Discontinuation of Ticagrelor or Clopidogrel on Bleeding: Essential Role of Antifibrinolytic Agents

We read with great interest the article in The Annals of Thoracic Surgery by Holm and colleagues1Holm M. Biancari F. Khodabandeh S. et al.Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting.Ann Thorac Surg. 2019; 107: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar that described 2311 patients who underwent coronary artery bypass grafting. Holm and colleagues1Holm M. Biancari F. Khodabandeh S. et al.Bleeding in patients treated with ticagrelor or clopidogrel before coronary artery bypass grafting.Ann Thorac Surg. 2019; 107: 1690-1698Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar found an increased rate of severe bleeding in patients receiving ticagrelor 2 days before surgery and in those receiving clopidogrel 3 days before surgery. There are many factors affecting postoperative bleeding, including age, sex, body mass index, surgery type, surgery priority, preoperative medication, and intraoperative hemostatic, among others.2Vuylsteke A. Pagel C. Gerrard C. et al.The Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding.Eur J Cardiothorac Surg. 2011; 39: 924-930Crossref PubMed Scopus (98) Google Scholar The use of the antifibrinolytic agents aprotinin and tranexamic acid is common and has been shown to reduce bleeding significantly.3Wang X. Zheng Z. Ao H. et al.Effects of aprotinin on short-term and long-term outcomes after coronary artery bypass grafting surgery.Ann Thorac Surg. 2010; 89: 1489-1495Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 4Myles P.S. Smith J.A. Forbes A. et al.Tranexamic acid in patients undergoing coronary-artery surgery.N Engl J Med. 2017; 376: 136-148Crossref PubMed Scopus (197) Google Scholar Previous studies found that tranexamic acid significantly reduced blood loss and major bleeding in patients undergoing primary and isolated on-pump coronary artery bypass grafting without clopidogrel and aspirin cessation.5Shi J. Wang G. Lv H. et al.Tranexamic acid in on-pump coronary artery bypass grafting without clopidogrel and aspirin cessation: randomized trial and 1-year follow-up.Ann Thorac Surg. 2013; 95: 795-802Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Hence, we believe the use of intraoperative antifibrinolytic agents of the 2 groups (clopidogrel and ticagrelaor) should be included in the baseline variable and wonder whether this factor of the 2 groups is similar and unbiased. Bleeding in Patients Treated With Ticagrelor or Clopidogrel Before Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 107Issue 6PreviewWe evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y12 inhibitors. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 109Issue 1PreviewWe thank Liu and Ao for their interest1 in our work2 and the comments regarding the use of tranexamic acid and aprotinin in coronary artery bypass grafting. As they correctly point out, the use of tranexamic acid has been shown to be associated with a lower risk of bleeding in patients undergoing coronary artery bypass grafting.3 In addition, aprotinin has been found to decrease postoperative bleeding in patients undergoing coronary artery bypass grafting.4 However, aprotinin has been associated with thrombotic complications,5 which has limited its use. Full-Text PDF