Postoperative Bleeding Risk Under Continued the P2Y12 Receptor Antagonists Ticagrelor

Introduction Ticagrelor is used for the prevention of thrombotic events in patients with acute coronary syndrome or myocardial infarction with ST elevation. The drug is combined with acetylsalicylic acid (ASA - Aspirin) unless the latter is contraindicated. The FDA indication for ticagrelor is reduction of the rate of cardiovascular death, myocardial infarction (MI), and stroke in people with acute coronary syndrome or history of myocardial infarction. AHA/ACC Guidelines 2014 state It is reasonable to choose ticagrelor over clopidogrel for P2Y12 inhibition treatment in patients with NSTE-ACS treated with early invasive strategy and/or coronary stenting [1]. The most common side effects are shortness of breath (dyspnea, 14 %) and various types of bleeding, such as hematoma, gastrointestinal, subcutaneous, intracranial hemorrhage In addition to this, knowing the contraindications of Ticagrelor to prevent hemorrhagic complications. Case presentation A 60-year-old man was admitted to. He had been receiving loading dose 180mg ticagrelor and 250mg aspirin and Heparin for a recent acute coronary syndrome (ACS) that had been treated with one bare-metal stent and developed a major esophageal bleeding, pericardial effusion.48 hours later, the patient had a decreased level of consciousness. Computed tomography (CT) revealed an intracranial hemorrhage peri-rolandic. Patient presented a cardiogenic shock (cardiac pump failure related to loss of myocardial contractility) with EF 15 % (under dobutamine) and Hypovolemic shock (due to blood loss) combined. He proceeded to emergency cardiac transplantation operation. Apart from dual antiplatelet therapy (DAPT) with aspirin and ticagrelor, there were no other identified risk factors for increased bleeding. Conclusion In cardiac surgical, patients who are treated with ticagrelor & ASA until and after surgery, ticagrelor therapy is associated with a significantly higher blood loss, a significantly higher use of blood products and coagulation factors and higher incidence of rethoracotomies for bleeding. Consequently, Ticagrelor intake for ACS patients should be avoided or at least discontinued 3 days before cardiac surgery.