Antiplatelet Management After CABG
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A 58-year-old male smoker with no other medical history was referred to his cardiologist for typical angina on exertion over the last 6 months. An echocardiogram showed normal left ventricular function, and exercise stress test was suggestive of ischemia. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG).
What is your recommendation regarding postoperative antiplatelet therapy in this patient?
The correct answer is: B. Aspirin indefinitely plus clopidogrel initiated early postoperatively and continued for 12 months
There are five randomized studies that showed mixed results for the impact of clopidogrel in addition to aspirin in maintaining graft patency.1-5 A large meta-analysis incorporating all 5 randomized studies in addition to 6 observational studies demonstrated a lower incidence of vein graft occlusion by the addition of clopidogrel to aspirin with reduced 30-day mortality compared with aspirin alone in patients undergoing off-pump CABG.6 Another meta-analysis incorporating only the 5 randomized studies also showed a significantly lower incidence of vein graft occlusion at 1 year with aspirin plus clopidogrel versus aspirin alone but no improvement in arterial graft patency.7 A prospective study by Gurbuz et al. demonstrated decreased symptom recurrence and adverse cardiac events in patients following off-pump CABG when clopidogrel was added to aspirin versus aspirin monotherapy.8
The American College of Cardiology released an update to the guidelines on the use of dual antiplatelet therapy and assigned a Class IIB recommendation, indicating that it may be considered to use clopidogrel (initiating use early postoperatively) in addition to aspirin for up to 12 months.9 Therefore, in this patient who underwent off-pump CABG for stable ischemic heart disease, there are data to suggest he will have improved graft patency and potentially lower early mortality with early postoperative initiation of aspirin and clopidogrel. His lack of other risk factors put him at a lower risk of major bleeding events.
- Mannacio VA, Di Tommaso L, Antignan A, De Amicis V, Vosa C. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypaSS occlusion After off-pump procedures) randomised study. Heart 2012;98:1710-5.
- Sun JC, Teoh KH, Lamy A, et al. Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the Preoperative Aspirin and Postoperative Antiplatelets in Coronary Artery Bypass Grafting study. Am Heart J 2010;160:1178-84.
- Kulik A, Le May MR, Voisine P, et al. Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial. Circulation 2010;122:2680-7.
- Gao G, Zheng Z, Pi Y, Lu B, Lu J, Hu S. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial. J Am Coll Cardiol 2010;56:1639-43.
- Gao C, Ren C, Li D, Li L. Clopidogrel and aspirin versus clopidogrel alone on graft patency after coronary artery bypass grafting. Ann Thorac Surg 2009;88:59-62.
- Deo SV, Dunlay SM, Shah IK, et al. Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis. J Card Surg 2013;28:109-16.
- Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013;112:1576-9.
- Gurbuz AT, Zia AA, Vuran AC, Cui H, Aytac A. Postoperative clopidogrel improves mid-term outcome after off-pump coronary artery bypass graft surgery: a prospective study. Eur J Cardiothorac Surg 2006;29:190-5.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016;134:e123-55.