Reversing ticagrelor’s P2Y12 inhibition in life-threatening haemorrhage: a case-based review

Introduction

Ticagrelor is an oral reversible platelet P2Y12 inhibitor that improves ischemic outcomes in atherosclerotic cardiovascular disease, including the prevention of stent thrombosis after percutaneous coronary intervention, at the cost of increased bleeding risk.

Areas covered A comprehensive literature search was performed across PubMed and Web of Science (inception to January 2026). This case-based review outlines the current guidance surrounding bleeding events and emergent surgery on oral P2Y12 inhibitors, including treatment options for reversing their effects, and describes a novel ticagrelor reversal agent in two cases of life-threatening bleeding, one related to gastrointestinal hemorrhage and one associated with emergent coronary artery bypass graft surgery.

Expert opinion

Ticagrelor is a first-line treatment for acute coronary syndromes but is associated with heightened bleeding risk, especially when combined with aspirin. Ticagrelor’s reversibility may offer advantages over the irreversibly-acting thienopyridine P2Y12 inhibitors. Patients treated with potent antiplatelet regimens may require rapid and effective restoration of hemostatic activity in addition to supportive measures in those presenting with life-threatening hemorrhage or requiring emergent surgery. We summarize the current available treatment options to reverse antiplatelet activity and highlight the role of ticagrelor reversal with bentracimab in improving hemostasis in emergency settings.