Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: the TiCAB trial

Abstract

Aims The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared the efficacy of ticagrelor and aspirin after CABG. Methods and results We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group [hazard ratio 1.19; 95% confidence interval (CI) 0.87–1.62; P = 0.28]. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53–1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38–1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36–1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70–2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71–1.92; P = 0.53). Conclusion In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated. ClinicalTrials.gov Identifier NCT01755520.

Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis

“…For clinical (secondary) outcomes, the results of our network meta-analysis show no differences in effect estimates among multiple treatment comparisons; nonetheless, these were not our prespecified primary outcomes. Interestingly, the recently published and prematurely terminated trial that compared ticagrelor with aspirin after coronary artery bypass graft surgery showed no important differences in major adverse cardiovascular events or bleeding between the monotherapies 50. These findings support the need for studies that evaluate dual antiplatelet therapy after coronary artery bypass graft surgery.…”

Ticagrelor as an Alternative Antiplatelet Therapy in Cardiac Patients Non-Sensitive to Aspirin

“…Ticagrelor, a “next generation” P2Y12 receptor inhibitor is an alternative antiplatelet therapy commonly prescribed to patients with CAD. It has demonstrated its efficacy as an antiplatelet medication when compared with ASA and clopidogrel [ 20 , 43 ]. The THEMIS trial conducted by Steg et al in 2019 demonstrated that patients with stable CAD and diabetes benefited from taking ticagrelor in combination with ASA, compared to ASA and a placebo [ 23 ].…”

Cardiac Surgery 2019 Reviewed

“…trial did not demonstrate an advantage of adding ticagrelor to aspirin in patients fresh after coronary bypass surgery. 33 One of the most interesting observations, this year, came from the Swedeheart registry, where the investigators demonstrated a 40% risk reduction in mortality by using statins (and also using renin-angiotensin-aldosterone system inhibitors) postoperatively (►Fig. 2D).…”