Clopidogrel After Surgery for Coronary Artery Disease - CASCADE


The goal of this trial was to compare treatment with aspirin and clopidogrel compared with aspirin and placebo after coronary artery bypass surgery (CABG).


Aspirin and clopidogrel would be superior in preventing saphenous vein graft intimal hyperplasia.

Study Design

  • Parallel
  • Placebo Controlled
  • Randomized

Patients Screened: 126
Patients Enrolled: 113
Mean Follow Up: 1 year
Mean Patient Age: 65 years
Female: 9%

Patient Populations:

  • Patients undergoing multivessel CABG that involves at least two saphenous vein grafts

Primary Endpoints:

  • Saphenous vein graft intimal area by intravascular ultrasound

Secondary Endpoints:

  • Saphenous vein graft patency
  • Major adverse cardiac events
  • Bleeding

Drug/Procedures Used:

After CABG involving at least two saphenous vein grafts, patients were randomized to aspirin and clopidogrel (n = 56) versus aspirin and placebo (n = 57).

Principal Findings:

Overall, 113 patients were randomized. There was no difference in baseline characteristics between the groups. In the aspirin and clopidogrel group, the mean age was 65 years, 9% were women, 25% were diabetics, off-pump CABG was performed in 5.4%, and the mean number of bypasses received was 3.6 per patient.

The primary outcome, vein graft intimal area at 1 year, was 4.1 mm2 with aspirin and clopidogrel versus 4.5 mm2 with aspirin and placebo (p = 0.44). Overall graft patency was 95.2% versus 95.5% (p = 1.0), internal mammary artery patency was 96.6% versus 100% (p = 0.90), and saphenous vein graft patency was 94.3% versus 93.2% (p = 0.69), respectively.

Major adverse cardiac events were 7.1% versus 8.8% (p = 1.0), all-cause death was 0% versus 1.8% (p = 1.0), myocardial infarction was 7.1% versus 1.8% (p = 0.21), and major bleeding was 1.8% versus 0% (p = 0.50), respectively.


After CABG, the addition of clopidogrel to aspirin is not superior to aspirin alone. Clopidogrel did not reduce saphenous vein graft intimal hyperplasia at 1 year, nor did it improve graft patency or reduce major adverse cardiac events. Major bleeding appeared to be the same in both groups. It is unknown if clopidogrel or a newer antiplatelet agent (prasugrel or ticagrelor) would have produced benefit if it were studied in more patients with longer duration of follow-up.


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.

Presented by Dr. Alexander Kulik at the American Heart Association Scientific Sessions, Orlando, FL, November 16, 2009.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Platelet Aggregation Inhibitors, Saphenous Vein, Mammary Arteries, Coronary Artery Bypass, Off-Pump, Coronary Disease, Ticlopidine, Piperazines, Hyperplasia, Diabetes Mellitus

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