Impact of the timing of P2Y12 inhibitor discontinuation prior to CABG in patients with left main disease: Results from the excel trial

BACKGROUND Guidelines recommend discontinuing P2Y12 inhibitors >5 days before CABG, but this interval is not always practical or feasible. In the EXCEL trial, 1905 pts with left main coronary artery disease (LMCAD) and low/intermediate SYNTAX scores were randomized to PCI (n=948) or CABG (n=957). We examined the effect of recent P2Y12 inhibitor use on post-CABG outcomes. METHODS Pts assigned to CABG were grouped based on recent P2Y12 inhibitor use (<2 weeks before randomization) and, among recent users, whether surgery was deferred for the recommended interval (≥5 days for clopidogrel/ticagrelor, ≥7 days for prasugrel). The primary endpoint was a composite of death, stroke, or MI at 3 years. RESULTS Of 957 CABG-assigned pts, 242 (25.3%) were recent P2Y12 inhibitor users in whom surgery was deferred (Group A); 137 (14.3%) were recent users in whom it was not deferred (Group B); and 544 (56.8%) were not recent users (Group C). The main reasons for not deferring CABG were clinical instability (38.7%) and physician preference (21.9%). Groups A and B had more recent MIs than group C (p<0.0001) but no other major baseline differences. Group B had more off-pump surgery (p<0.0002), intra-operative RBC transfusion (p=0.003), and unplanned hemodynamic support (p=0.0001). P2Y12 inhibitor use prior to CABG was associated with a higher 30-day rate of major adverse events, driven by more blood transfusions (Table). There was no significant difference between groups in the primary endpoint at 3 years in unadjusted analysis (Table), or after Cox multivariable analysis (P value for all comparisons >0.2). CONCLUSION In the EXCEL trial, performing CABG in pts with LMCAD before the recommended P2Y12 inhibitor washout period was not associated with major differences in early or late clinical outcomes; however, pts with recent P2Y12 inhibitor exposure did require more blood transfusions. (Table Presented).