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Use of aspirin and clopidogrel after coronary artery bypass graft surgery
Noelle de Leon1, Cynthia A Jackevicius
1College of Pharmacy, Western University of Health Sciences, Pomona, CA, USA. nksdeleon@gmail.com
Insights
Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel after coronary artery bypass graft (CABG) surgery shows limited evidence for improving graft patency. More research is needed to confirm clinical benefits and guide recommendations.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
- Surgical Outcomes
Background:
- Dual antiplatelet therapy (DAPT) using aspirin and clopidogrel is a common treatment post-cardiac procedures.
- The efficacy of DAPT following coronary artery bypass graft (CABG) surgery requires further investigation.
Purpose of the Study:
- To systematically evaluate the existing evidence on the use of DAPT after CABG surgery.
- To determine if DAPT improves graft patency and clinical outcomes in patients undergoing CABG.
Main Methods:
- A comprehensive literature search was conducted across major databases (PubMed, EMBASE, Cochrane) for relevant studies.
- Included peer-reviewed studies evaluating DAPT use in adult humans post-CABG, encompassing randomized trials and observational studies.
Main Results:
- Four randomized trials on surrogate endpoints showed mixed results regarding graft patency, with most not demonstrating improvement.
- Nine studies on clinical outcomes yielded varied findings, including diminished DAPT benefits in certain patient groups and trends toward reduced mortality in others.
- Observational studies suggested feasibility of DAPT in off-pump CABG and some reduction in in-hospital mortality, but long-term effects remain unclear.
Conclusions:
- Current evidence supporting DAPT use after CABG is primarily derived from subgroup analyses, observational studies, and trials with surrogate endpoints.
- The majority of clinical trials have not shown improved graft patency with DAPT post-CABG.
- Definitive recommendations for DAPT use after CABG require further robust evidence from randomized controlled trials focusing on clinical outcomes.
Objective:
To evaluate the evidence for the use of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel following coronary artery bypass graft (CABG) surgery.
Data Sources:
Literature was accessed through PubMed (1950-November 2011), EMBASE (1976-November 2011), and the Cochrane databases using the terms clopidogrel and coronary artery bypass graft. Citations from available articles were used for additional references and ClinicalTrials.gov was accessed for abstracts of ongoing studies.
Study Selection And Data Extraction:
Peer-reviewed studies that evaluated DAPT use after CABG surgery in adult humans were assessed for inclusion.
Data Synthesis:
Four randomized clinical trials evaluating surrogate end points and 9 studies (3 subgroup analyses, 6 observational) evaluating clinical outcomes were reviewed. Three clinical trials assessing surrogate end points failed to demonstrate an improvement in graft patency with DAPT use, while 1 clinical trial found an increase in graft patency. As for clinical outcomes, 1 subgroup analysis demonstrated that the benefit of DAPT post-CABG after a non-ST-elevation acute coronary syndrome diminished following surgery, while an observational study demonstrated a trend toward decreased mortality. In post-CABG patients who did not experience acute coronary syndrome, 2 subgroup analyses proved inconclusive and an observational study found DAPT use to be associated with reducing in-hospital mortality, while another observational study was not associated with reduced long-term mortality. Three observational studies in off-pump CABG patients showed that DAPT use was feasible.
Conclusions:
Evidence for DAPT use following CABG is limited to subgroup analyses, observational studies, and trials with surrogate end points. The majority of clinical trials have failed to demonstrate an improvement in graft patency with DAPT. Current evidence does not support the use of DAPT to improve graft patency, and more evidence from randomized controlled trials assessing clinical outcomes is necessary to make definitive recommendations.
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