"RAPID CABG is the first and only randomized study to evaluate the safety of early surgery. We found that an early surgical strategy two to three days after ticagrelor cessation was noninferior in incurring severe or massive bleeding compared to delaying surgery until five to seven days after stopping ticagrelor," Dr. Derek So of the University of Ottawa Heart Institute, in Canada, said in a presentation of the findings at the American Heart Association (AHA) virtual scientific sessions.
"We think that the results of our study might have implications on future North American guidelines by decreasing the time to surgery and increasing evidence or level of evidence in European and Asian guidelines," Dr. So said.
Current guidelines from the AHA and American College of Cardiology advise waiting at least five days after ticagrelor cessation before performing CABG. The 2017 European Society of Cardiology guidelines suggest waiting at least three days.
The RAPID CABG study tested whether a shorter waiting time for surgery after stopping ticagrelor is safe in 143 adults with acute coronary syndrome taking ticagrelor and requiring non-emergent CABG; 72 were randomly allocated to early surgery (two to three days after stopping ticagrelor) and 71 to delayed surgery (five to seven days after stopping ticagrelor). Baseline characteristics were similar in both groups, including age, gender and coexisting health conditions.
"Not surprisingly, in the early group, there was more residual antiplatelet effects from the ticagrelor," Dr. So reported.
However, in the per-protocol analysis of 65 patients in the early group and 58 in the delayed group, there was no increased risk of early post-surgical bleeding in the early group. In the early group, 4.6% had Class 3 or 4 bleeding (primary outcome) compared to 5.2% in the delayed group, "meeting criteria for noninferiority," Dr. So said.
The median time to surgery was three days in the early group compared to six days in the delayed group. The average length of hospital stay was reduced by three days among the participants in the early-surgery group compared to the delayed-surgery group.
At six months, there were more adverse cardiac events in the delayed group (13.0%) than the early group (5.6%).
"We discovered no significant increase in bleeding when people had bypass surgery after 2-3 days of discontinuing ticagrelor. These findings may be surprising based on the assumption that the presence of a strong blood thinner should predispose people to severe bleeding," Dr. So said in a conference statement.
"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," Dr. So added.
He noted that while the study was not large enough to evaluate whether early surgery protects people from experiencing early recurrent heart attacks or angina, "it opens this hypothesis and may prompt future research in the area."
Offering outside perspective on the study, Dr. Joanna Chikwe of the Smidt Heart Institute, Cedars-Sinai Medical Center, in Los Angeles, said the "topline message is - if you've got an indication (for CABG), waiting for surgery does not serve you."
SOURCE: https://bit.ly/3kE1RL7 American Heart Association Scientific Sessions 2021, presented November 13, 2021.
By Megan Brooks
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