Early versus Delayed CABG: RAPID CABG Trial Findings Support Shorter Wait Time After Ticagrelor Cessation

The RAPID CABG trial, a randomized, open-label, noninferiority study, found that performing surgery 2 to 3 days after stopping ticagrelor was not associated with a higher risk of perioperative bleeding than a longer delay. These findings suggest that reducing the waiting period before surgery may be a safe option and help shorten hospital stays.

The researchers note that perioperative bleeding is a major concern in patients with ACS who require CABG surgery while on ticagrelor, a key component of dual antiplatelet therapy used to prevent thrombotic events. Although ticagrelor reduces cardiovascular risks, it also increases bleeding susceptibility, making the timing of surgery crucial. Current guidelines recommend a 5 to 7-day gap between ticagrelor cessation and CABG to minimize bleeding risk. However, this delay can extend hospitalization and potentially lead to complications, highlighting the need for a balanced approach to optimize patient outcomes.

To fill this knowledge gap, Derek Y. F. So, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada, and colleagues aimed to determine if performing CABG surgery 2 to 3 days after stopping ticagrelor is as safe and effective as waiting 5 to 7 days.

For this purpose, the researchers conducted the RAPID CABG trial, a noninferiority, open-label randomized study with six months of follow-up. It included ACS patients on ticagrelor requiring CABG, enrolled from Canadian tertiary centers (2016–2021), with data analyzed until 2023. The study compared early (2–3 days) vs. delayed (5–7 days) CABG. The primary outcome assessed noninferiority in class 3 or 4 perioperative bleeding (UDPB) with an 8% margin. Additionally, 12-hour chest tube drainage was analyzed for noninferiority, while other bleeding, ischemic, and length-of-stay outcomes were evaluated for superiority.

The following were the key findings of the study:

• Among 143 randomized patients, the median age was 65 years, with 117 males (82%) and 26 females (18%). 123 patients (86%) underwent surgery within the allocated time frame (per protocol).
• The median time to surgery was 3 days in the early group and 6 days in the delayed group.
• Severe or massive UDPB occurred in 4.6% of early-group patients and 5.2% of delayed-group patients.
• Median chest tube drainage was 470 mL in the early group and 495 mL in the delayed group.
• Median hospital stay was 9 days in the early group and 12 days in the delayed group.

The researchers found that performing CABG surgery 2 to 3 days after ticagrelor cessation was a safe and noninferior strategy concerning severe or massive perioperative bleeding. Their findings suggest that reducing the waiting period before surgery does not increase bleeding risk and may help shorten hospital stays. This approach could be particularly beneficial for patients with high-risk anatomy, recurrent ischemic symptoms, or clinical instability.

"The study supports reconsidering current guidelines to optimize surgical timing, improving both patient outcomes and hospital resource utilization," the researchers concluded.

Reference:

So DYF, Wells GA, Lordkipanidzé M, et al. Early vs Delayed Bypass Surgery in Patients With Acute Coronary Syndrome Receiving Ticagrelor: The RAPID CABG Randomized Open-Label Noninferiority Trial. JAMA Surg. Published online February 19, 2025. doi:10.1001/jamasurg.2024.7066