A randomized trial has found that performing coronary artery bypass graft surgery 2 to 3 days following ticagrelor cessation may be noninferior to the conventional waiting period of 5 to 7 days in terms of perioperative bleeding.

In the RAPID CABG trial, published in JAMA Surgery, researchers enrolled 143 patients with acute coronary syndrome (ACS) across Canadian tertiary centers. Patients underwent either early coronary artery bypass graft (CABG) (median of 3 days post–ticagrelor cessation) or delayed CABG (median of 6 days). Severe or massive perioperative bleeding occurred in 4.6% of the patients in the early group and 5.2% of those in the delayed group (difference = −0.6%, 95% confidence interval [CI] = −8.3% to 7.1%, P = .03 for noninferiority). Chest tube drainage at 12 hours was also comparable (470 mL vs 495 mL, P = .01 for noninferiority). The early group had a shorter median hospital stay (9 vs 12 days, P < .001).

"The data support a reduction in the delay between ticagrelor cessation and CABG surgery and may decrease hospital length of stay," said lead author Derek Y. F. So, MD, of the University of Ottawa Heart Institute, and colleagues. Shortening wait times to CABG may be particularly beneficial among patients with high-risk anatomy or recurrent ischemic symptoms.

Conducted between 2016 and 2021, the study was designed as a noninferiority trial with an 8% prespecified margin. Current guidelines recommend ticagrelor cessation at least 3 to 5 days prior to elective CABG based on pharmacodynamic data rather than randomized trials. This study provided clinical evidence supporting an earlier surgical approach.

At 6 months, major adverse cardiovascular events occurred in 5.6% of the patients in the early group and 13.0% of those in the delayed group, though the study was not powered to assess ischemic outcomes. Platelet reactivity prior to surgery was significantly lower in the early group (200 vs 251 P2Y12 reaction units, P < .001), consistent with ticagrelor’s expected pharmacodynamic effects.

Limitations included a predominantly male cohort (82%) and the exclusion of urgent CABG and valve surgery cases. The study’s pilot design also resulted in a wider noninferiority margin than might be used in a larger trial.

Full disclosures are available in the published study.