Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG)

Abstract

Background: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial investigated whether ticagrelor added to standard aspirin improves SVG patency at one year after CABG. Methods: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80mg or 100mg). The primary outcome was SVG occlusion at one year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was one-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG or sudden death. Results: Among 499 randomized patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was Acute Coronary Syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), OR 1.29 [95% CI: 0.73 -2.30]; P =0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (OR 1.22, [95% CI: 0.72-2.05]). Conclusions: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at one year after CABG. Clinical Trial Registration: URL: https://clinicaltrials.gov; Unique Identifier: NCT02352402.

Secondary Prevention Medications Post Coronary Artery Bypass Grafting Surgery—A Literature Review

“…38 Furthermore, Zhao et al (2018) 39 reported improved graft patency with ticagrelor and aspirin when compared to aspirin alone, however this was not accompanied with a statistically significant difference in MACE or MI. This contrasts the data from the POP-CABG trial 40 which found no difference in SVG occlusion rates in 499 patients after a year of DAPT with ticagrelor (compared to aspirin and placebo).…”

Dual Antiplatelet Therapy with Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients Undergoing Coronary Artery Bypass Graft Surgery

“…However, this benefit was not confirmed in another newly published randomized study on the same topic. 40 …”

“…Moreover, DAPT was associated with a 31% higher risk of bleeding in the overall study population. It is noteworthy that almost all of the studies involved were designed to evaluate the efficacy of DAPT on graft patency rather than its effects on clinical outcomes, were underpowered, 15 , 16 , 23 had substantially heterogeneous populations, 14 , 40 and used different DAPT definitions, thereby precluding conclusive inference and resulting in inconsistent guideline recommendations 2 , 24 , 25 and variation in real‐world clinical practice patterns. 41 …”

Anticoagulation and antiplatelet therapy post coronary artery bypass surgery

“…The recently completed POPular‐CABG RCT also evaluated the addition of ticagrelor to aspirin in post‐CABG patients but found no difference in SVG patency at 1‐year 50 . Although an important difference with the POPular‐CABG and DACAB trials were the dose of aspirin (80 and 100 mg, respectively), this did not have the expected effect on patency rates (~91% and ~77%, respectively).…”