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DAPT With Ticagrelor With Vein Graft Failure After CABG
Quick Takes
- Dual antiplatelet therapy with aspirin and ticagrelor (Ticagrelor DAPT) was associated with lower risk of vein graft failure post-CABG surgery and increased risk of clinically relevant bleeding post-CABG when compared to aspirin monotherapy.
- Subgroup analysis suggested greater benefit with Ticagrelor DAPT in those undergoing CABG for ACS and those with high SYNTAX score (>22).
- Well-powered clinical trials are needed to better establish efficacy and safety of dual antiplatelet therapy with ticagrelor and aspirin in patients undergoing CABG.
Study Questions:
What is the safety and efficacy of dual antiplatelet therapy with aspirin and ticagrelor (Ticagrelor DAPT) post–coronary artery bypass graft (CABG) surgery?
Methods:
Ticagrelor DAPT post-CABG surgery was studied in an individual patient-level meta-analysis. The primary analysis assessed the incidence of saphenous vein graft (SVG) failure per graft (primary outcome) in randomized clinical trials (RCTs) comparing Ticagrelor DAPT with aspirin alone. Secondary outcomes were SVG failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events.
Results:
A total of 871 patients with 972 SVGs from four RCTs were included. Overall, Ticagrelor DAPT was associated with a significantly lower incidence of SVG failure (11.2%) per graft than was aspirin alone (20%; difference, −8.7% [95% CI, −13.5% to −3.9%]; odds ratio [OR], 0.51 [95% CI, 0.35 to 0.74]; p < 0.001) and was associated with a significantly lower incidence of SVG failure per patient (13.2% vs. 23.0%, difference, −9.7% [95% CI, −14.9% to −4.4%]; OR, 0.51 [95% CI, 0.35 to 0.74]; p < 0.001). Ticagrelor DAPT (22.1%) was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events than was aspirin (8.7%; difference, 13.3% [95% CI, 8.6% to 18.0%]; OR, 2.98 [95% CI, 1.99 to 4.47]; p < 0.001), but not BARC type 3 or 5 bleeding events (1.8% vs. 1.8%, difference, 0% [95% CI, −1.8% to 1.8%]; OR, 1.00 [95% CI, 0.37 to 2.69]; p = 0.99). Compared with aspirin, ticagrelor monotherapy was not significantly associated with SVG failure (19.3% vs. 21.7%, difference, −2.6% [95% CI, −9.1% to 3.9%]; OR, 0.86 [95% CI, 0.58 to 1.27]; p = 0.44) or BARC type 2, 3, or 5 bleeding events (8.9% vs. 7.3%, difference, 1.7% [95% CI, −2.8% to 6.1%]; OR, 1.25 [95% CI, 0.69 to 2.29]; p = 0.46).
Subgroup analysis suggested a significant interaction based on SYNTAX score, with benefit from Ticagrelor DAPT restricted to those with SYNTAX score >22 (p = 0.04). Patients undergoing CABG for acute coronary syndrome (ACS) were also noted to have a greater benefit with Ticagrelor DAPT but the interaction term for this subgroup did not reach statistical significance (p = 0.61).
Conclusions:
Among patients undergoing CABG surgery, adding ticagrelor to aspirin was associated with a significantly decreased risk of vein graft failure. However, this was accompanied by a significantly increased risk of clinically important bleeding.
Perspective:
These results are intriguing, and on first glance, argue for Ticagrelor DAPT after CABG. On careful review, it is noted that while most patients included in this analysis underwent CABG for stable angina, the greatest benefit with Ticagrelor DAPT was noted in those who received CABG for ACS and in those with SYNTAX score >22. These findings suggest an increasing role for Ticagrelor DAPT for these subpopulations with higher disease burden. Nonetheless, future work with well-powered clinical trials will need to better define risk/benefit profile of Ticagrelor DAPT before its use in routine practice can be recommended.
Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Anticoagulation Management and ACS, Cardiac Surgery and SIHD, Interventions and ACS, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina, Stable, Anticoagulants, Aspirin, Cardiac Surgical Procedures, Coronary Artery Bypass, Hemorrhage, Myocardial Ischemia, Platelet Aggregation Inhibitors, Risk, Saphenous Vein, Ticagrelor
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