Early CABG After Ticagrelor Safe in Acute Coronary Syndrome

TOPLINE:

In patients with acute coronary syndrome (ACS), coronary artery bypass graft (CABG) surgery performed 2-3 days after ticagrelor cessation showed noninferiority in bleeding risk and reduced hospital stay compared with surgery after 5-7 days, according to the RAPID CABG trial.

METHODOLOGY:

• The RAPID CABG trial was a noninferiority, open-label randomized trial conducted at two centers in Canada, including 143 patients with ACS who received ticagrelor and were enrolled between 2016 and 2021.
• Participants were randomly assigned to receive early CABG (2-3 days after ticagrelor cessation; n = 65 in the per-protocol analysis) or delayed CABG (5-7 days after cessation; n = 58 in the per-protocol analysis).
• The median age of the participants was 65 years, and 82% of them were men.
• The primary outcome was class 3 or 4 bleeding according to the universal definition of perioperative bleeding (UDPB), and the secondary outcomes were bleeding and ischemic events.
• The follow-up duration was 6 months.

TAKEAWAY:

• Severe or massive UDPB occurred in 4.6% of patients in the early group vs 5.2% of those in the delayed group (P = .03 for noninferiority).
• Median chest tube drainage was noninferior between the groups (between-group difference, −25 mL; P = .01).
• The total hospital stay was significantly shorter in the early surgery group than in the delayed group (median stay, 9 days vs 12 days; P < .001).
• At 6 months, major adverse cardiovascular events occurred in 5.6% of patients in the early group and 13.0% of those in the delayed group.

IN PRACTICE:

“This study found that an early surgical strategy, 2-3 days after ticagrelor cessation, was noninferior in incurring perioperative bleeding. The data support a reduction in the delay between ticagrelor cessation and CABG surgery and may decrease hospital length of stay,” the authors wrote.

SOURCE:

The study was led by Derek Y. F. So, MD, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. It was published online on February 19, 2025, in JAMA Surgery.

LIMITATIONS:

The study predominantly included men. The findings could not be extrapolated to patients who had ad hoc stenting at presentation or required valve surgery. Additionally, as the study was conducted in only two high-volume centers, there may have been limitations on external generalizability. The study’s small size prevented conclusions on individual bleeding components, and clinicians were not blinded to surgery timing.

DISCLOSURES:

The study was funded by the Canadian Institutes of Health Research and the University of Ottawa Heart Institute. Several authors reported receiving grants or personal fees from various sources outside the submitted work. Details are provided in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.