DAPT and Urgent CABG in ACS: Impact of P2Y12 Inhibitor Choice and Intraoperative Hemoadsorption on Perioperative Bleeding: Comparative Real-World Analysis

All articles of this category (opens in new window) Background: ACS patients on DAPT requiring urgent CABG are at high risk for bleeding complications. Published reports show severe CABG bleeding in up to 1/3 of these cases. Intraoperative hemoadsorption (HA) can remove ticagrelor from circulation and potentially mitigate this high perioperative bleeding risk. Methods: We compared CABG bleeding rates in two cohorts according to two different strategies: Group 1: Ticagrelor + Aspirin + intraoperative HA from the International Safe and Timely Antithrombotic Removal (STAR) registry (ClinicalTrials.gov identifier: NCT05077124). Group 2 was derived from the North Rhine-Westphalia surgical myocardial infarction registry, consisting of Clopidogrel + Aspirin patients. The primary outcome was the CABG-specific bleeding endpoint, summarized by Bleeding Academic Research Consortium (BARC)-4 rates. Results: Prior to matching, Group 1 ( n = 136) compared to Group 2 ( n = 820) showed a significant difference in age ( p < 0.001) and chronic renal disease ( p = 0.04). Crude BARC-4 rates were significantly lower in Group 1 compared with Group 2 (8.9% vs. 32.6%, p < 0.0001), as was the rate of patients requiring ≥ 5 units of red blood cells within 24 hours ( p < 0.0001) and 24-hr chest tube drainage ( p < 0.0001). The 1:3 propensity score adjusted outcomes (113 vs. 339 patients) showed similar results of BARC-4 bleeding events (9.7% vs. 32.3%, p < 0.0001). Overall, BARC-4 bleeding events were more likely in group 2 (OR: 4.7, 95% CI: 2.36–9.49). Conclusion: The current analysis of two different DAPT strategies in ACS used in real-world practice showed significant reductions in severe bleeding complications after CABG with ticagrelor and intraoperative HA. Current ACS guidelines already recommend ticagrelor over clopidogrel in ACS due to better protection from ischemic events. The present analysis, however, adds the advantage of significantly reduced BARC Type 4 bleeding with intraoperative HA among the 5 to 10% of ACS patients who need urgent CABG. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany