Association of Dual Antiplatelet Therapy With Ticagrelor With Vein Graft Failure After Coronary Artery Bypass Graft Surgery

Abstract

IMPORTANCEThe role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear.OBJECTIVE To compare the risks of vein graft failure and bleeding associated with ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy vs aspirin among patients undergoing coronary artery bypass graft surgery.DATA SOURCES MEDLINE, Embase, and Cochrane Library databases from inception to June 1, 2022, without language restriction. STUDY SELECTION Randomized clinical trials (RCTs) comparing the effects of ticagrelor DAPT or ticagrelor monotherapy vs aspirin on saphenous vein graft failure.DATA EXTRACTION AND SYNTHESIS Individual patient data provided by each trial were synthesized into a combined data set for independent analysis. Multilevel logistic regression models were used. MAIN OUTCOMES AND MEASURESThe primary analysis assessed the incidence of saphenous vein graft failure per graft (primary outcome) in RCTs comparing ticagrelor DAPT with aspirin. Secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included RCTs comparing ticagrelor monotherapy with aspirin.RESULTS A total of 4 RCTs were included in the meta-analysis, involving 1316 patients and 1668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT (median age, 67 years [IQR, 60-72 years]; 65 women [14.9%]; 370 men [85.1%]) and 436 received aspirin (median age, 66 years [IQR,[61][62][63][64][65][66][67][68][69][70][71][72][73]; 63 women [14.5%]; 373 men [85.5%]). Ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%; difference, −8.7% [95% CI, −13.5% to −3.9%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001) and was associated with a significantly lower incidence of saphenous vein graft failure per patient

Late Myocardial Infarction and Repeat Revascularization after Coronary Artery Bypass Grafting in Patients with Prior Percutaneous Coronary Intervention

“…Third, the fate of the previously implanted stents and atherosclerosis of native arteries might have been affected by the preoperative withdrawal of antiplatelet drugs and anticoagulants. Similarly, antithrombotic therapy might have had an impact on thrombotic events, early and late, after surgery [ 14 ]. However, collinearity between the use of antithrombotic drugs and prior PCIs prevents a reliable analysis of the impact of using these drugs on the outcomes.…”

Dual Antiplatelet Therapy With Ticagrelor and Vein Graft Failure After Coronary Artery Bypass Graft Surgery

“…First, this study did not report statistical heterogeneity . Assessing heterogeneity is important in meta-analyses using individual patient data and those using aggregated data, particularly when the confidence intervals of effect estimates of individual studies do not overlap well.…”

“…To the Editor We have several concerns about the recent systematic review and meta-analysis that found ticagrelor and aspirin vs aspirin alone reduced the risk of saphenous vein graft failure after coronary artery bypass graft surgery.…”

Secondary prevention is as important as surgical technique

“…A 1993 meta‐analysis of seven RCTs including 1443 patients showed that the use of aspirin after CABG was associated with a lower risk of SVG occlusion 6 . A recent meta‐analysis involving 1316 patients and 1668 SVG showed that adding ticagrelor to aspirin was associated with a significantly lower incidence of SVG failure (11.2%) per graft than was aspirin (20%; difference, −8.7% [95% confidence interval, CI, −13.5% to −3.9%]; OR, 0.51 [95% CI, 0.35–0.74]; p < .001) 7 . Aggressive lipid‐lowering reduced progression of atherosclerosis in grafts in the post‐CABG trial 8 .…”

“… 6 A recent meta‐analysis involving 1316 patients and 1668 SVG showed that adding ticagrelor to aspirin was associated with a significantly lower incidence of SVG failure (11.2%) per graft than was aspirin (20%; difference, −8.7% [95% confidence interval, CI, −13.5% to −3.9%]; OR, 0.51 [95% CI, 0.35–0.74]; p < .001). 7 Aggressive lipid‐lowering reduced progression of atherosclerosis in grafts in the post‐CABG trial. 8 In addition, higher low‐density lipoprotein (LDL) levels during the first postoperative year were associated with significantly greater VGD 3 years after CABG in the aggressive cholesterol therapy to inhibit vein graft events trial.…”