Findings from the TACSI and TOP-CABG trials presented at ESC Congress 2025 add to discussions around antiplatelet therapy following CABG.

In TACSI, simultaneously published in NEJM, researchers compared ticagrelor plus aspirin or aspirin alone in approximately 2,200 patients who underwent CABG for acute coronary syndrome (ACS) (mean age of 66 years/14.4% women). The primary outcome was a composite of death, myocardial infarction, stroke or repeat revascularization, evaluated at one year. A key secondary outcome was net adverse clinical events, defined as a primary-outcome event or major bleeding.

A primary-outcome event occurred in 4.8% (53 patients) in the ticagrelor-plus-aspirin group compared with 4.6% (50 patients) in the aspirin-alone group at one year. Net adverse clinical events occurred in 9% of patients assigned to ticagrelor-plus-aspirin vs. 6% assigned to aspirin alone. Major bleeding was higher in the ticagrelor-plus-aspirin group (5%) compared with the aspirin-alone group (2%).

"Our 12-month data do not support the use of dual antiplatelet therapy (DAPT) over aspirin alone in ACS patients after CABG, given the lack of improvement in major adverse cardiac events and the increased risk of major bleeding," said Principal Investigator Anders Jeppsson, MD, PhD. "However, further long-term follow-up is needed."

In the TOP-CABG trial, researchers compared 12 months of DAPT with 12 months of de-escalated DAPT in more than 2,000 patients following CABG. Patients randomized to 12 months of DAPT received ticagrelor 90 mg twice daily plus aspirin 100 mg once daily for one year, while those in the de-escalated group received ticagrelor 90 mg twice daily plus aspirin 100 mg once daily for three months, then placebo twice daily plus aspirin 100 mg once daily for nine months.

In overall findings, noninferiority was demonstrated for the primary efficacy endpoint of graft occlusion, which occurred in 10.79% of patients' grafts in the de-escalated DAPT group and 11.19% in the DAPT group. The primary safety endpoint of clinically relevant bleeding was less frequent with de-escalated DAPT vs. DAPT (8.26% vs. 13.19% of patients), according to the researchers. No differences in secondary outcomes including graft failure, any graft stenosis, any graft occlusion or major adverse cardiac and cerebrovascular events, were observed across the two groups.

"There was no difference between the groups for secondary outcomes including graft failure, any graft stenosis, any graft occlusion or major adverse cardiac and cerebrovascular events, said Xin Yuan, MD. "In the largest CABG trial to date, a de-escalation strategy offered a better balance between graft patency protection and bleeding risk than DAPT. These findings may help to inform future guidelines regarding the benefits of a shorter period of DAPT during the early phase after CABG."