Ticagrelor Discontinuation Guidelines

Pre-Surgical Discontinuation

The European Society of Cardiology recommends discontinuing ticagrelor at least 3 days before elective surgery, with 5 days preferred for procedures with significant bleeding risk 1, 2, 3
The American College of Cardiology/American Heart Association guidelines recommend discontinuing ticagrelor at least 5 days before any surgery when possible 2
For coronary artery bypass graft surgery, ticagrelor should be withheld for 1 to 3 days, though 3-5 days is preferred to minimize bleeding risk 4, 1

The European Heart Journal recommends immediate discontinuation of ticagrelor when major bleeding occurs, but the decision must account for stent thrombosis risk, particularly within 2 weeks of PCI 1, 3
In high stent thrombosis risk scenarios, bridging therapy with IV reversible glycoprotein inhibitors (tirofiban or eptifibatide) or cangrelor may be considered 1, 3
Cangrelor is preferred due to its specific P2Y12 inhibition and quicker offset of action compared to glycoprotein inhibitors 1, 3

The American College of Cardiology recommends continuing ticagrelor for at least 12 months after acute coronary syndrome, regardless of stent type 5, 2, 6
In patients requiring oral anticoagulation for atrial fibrillation, ticagrelor can be discontinued earlier than 12 months, transitioning to dual therapy (OAC + P2Y12 inhibitor) or monotherapy 7, 5
For stable patients with prior PCI (>12 months) who remain at high ischemic risk and low bleeding risk, ticagrelor 60 mg twice daily plus aspirin may be considered 6

Patients with a body weight <60 kg, renal dysfunction, or concomitant use of anticoagulants are at higher bleeding risk and may require earlier discontinuation 2, 8
Fatal intracranial bleeds occurred more frequently with ticagrelor (0.1% vs 0.01%, P=0.02) 4
Non-CABG major bleeding was higher with ticagrelor (4.5% vs 3.8%, P=0.03) 4

Ticagrelor must be immediately discontinued in patients with active pathological bleeding or history of intracranial hemorrhage 9, 8
Active bleeding is an FDA boxed warning contraindication 9, 8
History of intracranial hemorrhage is an absolute contraindication 9, 8

Never use aspirin >100 mg daily with ticagrelor, as higher doses paradoxically decrease ticagrelor's effectiveness and increase bleeding risk 9, 8
Do not use low-molecular-weight heparin as bridging therapy when discontinuing ticagrelor for surgery in high stent thrombosis risk patients 1, 3

Antiplatelet therapy should be resumed within 24 hours after procedures if there are no bleeding complications 10
For patients who undergo PCI, ticagrelor should be restarted as soon as possible 10
After major bleeding resolves, the decision to restart should weigh ongoing ischemic risk against recurrent bleeding risk 1, 3

The American Academy of Otolaryngology-Head and Neck Surgery suggests that platelet transfusions do not reverse ticagrelor's antiplatelet effects because ticagrelor is a reversible P2Y12 inhibitor that remains in the plasma and immediately inhibits transfused platelets 11
The American Academy of Otolaryngology-Head and Neck Surgery recommends supportive hemostatic measures, including antifibrinolytics, such as tranexamic acid or aminocaproic acid, which may support hemostasis, though they do not reverse the platelet inhibitory effects 11
The American Academy of Otolaryngology-Head and Neck Surgery and the Stroke journal suggest that desmopressin may be considered to support hemostasis, though evidence is limited and it does not reverse antiplatelet effects 11, 12

The European Heart Journal recommends bridging therapy with cangrelor, an IV reversible P2Y12 inhibitor, for patients at extremely high risk of stent thrombosis when ticagrelor must be stopped 13
The European Heart Journal suggests that tirofiban or eptifibatide, IV reversible GP IIb/IIIa inhibitors, may be considered as alternatives for bridging therapy 13

The American Academy of Otolaryngology-Head and Neck Surgery and the Stroke journal recommend maximizing local hemostatic measures, administering antifibrinolytics, and considering desmopressin for patients with active bleeding on ticagrelor 11, 12
The European Heart Journal advises against using low-molecular-weight heparin as bridging therapy, as it does not reduce stent thrombosis risk and increases bleeding 13