Abstract 13362: Increased Bleeding and Poor Outcomes in Patients Who Require Cardiac Procedures While Receiving P2Y12 Inhibitors

Introduction: P2Y12 inhibitors (P2Y12i) reduce thrombotic risk in patients with acute coronary syndrome and in secondary prevention of atherothrombotic events, but dual antiplatelet therapy with a P2Y12i + aspirin increases bleeding risk. P2Y12i washout is recommended prior to procedures, but when procedures cannot be deferred, washout is precluded, thereby increasing periprocedural bleeding risk, with potential negative outcomes. Hypothesis: P2Y12i are associated with increased bleeding risk and poorer clinical and economic outcomes in invasive cardiovascular (CV) procedures. Methods: In a retrospective study of hospital chargemaster data (2017-2019), patients receiving P2Y12i (cangrelor, clopidogrel, prasugrel, ticagrelor, or ticlopidine) or aspirin without P2Y12i (control) prior to an invasive CV procedure were identified from hospital charge and ICD-10 codes. Inpatient bleeding, mortality, length of stay (LOS; days), and intensive care unit (ICU) LOS (days) were assessed. Results: Among 2,996,051 patients with invasive CT procedures, P2Y12i-treated patients had significantly higher bleeding rates versus control patients (4.2% vs 3.1% p<0.05). Coronary artery bypass graft (CABG) procedures were the most common. Heart valve procedures showed the highest bleeding rates. Both CABG and valve procedures showed significant increases in bleeding for patients with P2Y12i versus control patients (CABG 9.2% vs 5.7%; valve 17.2% vs 8.9%; both p<0.05). P2Y12i-treated patients with bleeding versus those without bleeding had significant increases in in-hospital mortality (CABG 5.0% vs 2.1%; valve 12.4% vs 4.8%), LOS (CABG 11.7 vs 10.7; valve 13.0 vs 11.6), and ICU LOS (CABG 8.4 vs 5.5; valve 11.2 vs 8.3) (all p<0.05). Similar findings were observed for other procedures. Conclusions: Invasive CV procedures in patients receiving P2Y12i were associated with increased bleeding rates. Patients with increased bleeding had poorer outcomes, including increased in-hospital mortality. Bleeding avoidance in P2Y12i-treated patients requires an adequate discontinuation period prior to invasive procedures. Delaying CV procedures, however, may result in suboptimal outcomes, highlighting the unmet need for a rapid reversal strategy for P2Y12i.