Inadequate antiplatelet pre-treatment in patients undergoing acute thoracic surgery. Risk for complications and cost.

Abstract: Introduction Prior to percutaneous coronary intervention (PCI) guidelines recommend that patients with ST- elevation myocardial infarction (STEMI) receive dual antiplatelet therapy (DAPT) consisting of P2Y12 inhibition and acetylsalicylic acid (aspirin). However, in rare occasions, patients admitted with STEMI as preliminary diagnosis require acute thoracic surgery and oral P2Y12 inhibitors increases the bleeding risk over several hours. Cangrelor is an intravenous reversible P2Y12 antagonist with normal platelet function returning within 60 minutes and might therefore be an attractive alternative to oral P2Y12 inhibition.Aim Firstly, to quantify P2Y12 pre-treatment with ticagrelor in patients undergoing acute thoracic surgery and the mortality and morbidity rate associated with DAPT prior to surgery. Secondly, to estimate cost-benefit differences between cangrelor and ticagrelor pre-treatment.Material and Methods A descriptive cohort study using retrospective data. The inclusion criteria were patients undergoing acute thoracic surgery (≤ 24 hours) between January 2015 and December 2017, in the catchment area of Örebro University Hospital. Patients were stratified into groups depending on whether they had received pre-treatment with DAPT or not before surgery. Statistical analyses were made in SPSS and Excel.Results A total of 50 patients were included. 8 patients received DAPT before surgery. There was no mortality in patients receiving DAPT but TIMI major bleeding was more frequent compared to the group with no pre-treatment. The DAPT group required numerically more units of platelets and plasma, however the result was not significant. Direct treatment costs for ticagrelor was 20.14 SEK (the dosage is 2 tablets) and cangrelor was 3 059 SEK.Conclusions DAPT pre-treatment with ticagrelor was not associated with increased mortality but TIMI major bleeding was more frequent compared to the group with no pre-treatment. Direct treatment costs with cangrelor was higher compared to ticagrelor treatment. Further studies, with larger study samples, are needed to investigate complications associated with P2Y12 pre-treatment in patients undergoing acute thoracic surgery.