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Ticagrelor-based antiplatelet regimens in patients treated with coronary artery bypass grafting: a meta-analysis of
Moritz von Scheidt1,2, Dario Bongiovanni2,3, Ulrich Tebbe4
1Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
Insights
Ticagrelor-based regimens significantly reduce mortality and major adverse cardiac events in patients after coronary artery bypass grafting (CABG). This meta-analysis found no increased bleeding risk, suggesting a favorable safety profile for ticagrelor in CABG patients.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- The optimal antiplatelet strategy following coronary artery bypass grafting (CABG) is not well-established.
- Existing research lacks comprehensive meta-analyses on ticagrelor-based regimens in the CABG population.
Purpose of the Study:
- To conduct the first meta-analysis evaluating clinical outcomes of ticagrelor-based antiplatelet therapy in patients who have undergone CABG.
- To compare the efficacy and safety of ticagrelor-based regimens against control antiplatelet strategies post-CABG.
Main Methods:
- A systematic search of scientific databases was performed for randomized controlled trials comparing ticagrelor-based regimens to control regimens in CABG patients, up to April 1, 2019.
- The primary outcome was all-cause death; secondary outcomes included myocardial infarction (MI), cardiac death, major adverse cardiac events (MACE), stroke, and bleeding.
- Five trials involving 3996 patients were included in the quantitative synthesis.
Main Results:
- Ticagrelor-based regimens significantly reduced all-cause death (OR 0.61; P=0.007), cardiac death (OR 0.58; P=0.007), and MACE (OR 0.79; P=0.03) compared to control regimens.
- No significant differences were observed in the rates of MI (OR 0.76; P=0.22), stroke (OR 0.99; P=0.98), or bleeding (OR 1.04; P=0.41).
- A significant treatment effect modification was noted for trials predominantly enrolling patients with acute coronary syndrome (P=0.038).
Conclusions:
- Ticagrelor-based antiplatelet strategies are associated with reduced mortality and MACE in CABG patients, without an increased risk of bleeding.
- The benefits of ticagrelor-based regimens appear more pronounced in patients with acute coronary syndrome.
- Further randomized trials focusing on this specific patient subset are warranted to confirm these findings.
Objectives:
The optimal antiplatelet strategy in patients undergoing CABG remains unclear. This is the first meta-analysis investigating the clinical outcomes associated with ticagrelor-based antiplatelet regimens in patients receiving CABG.
Methods:
Relevant scientific databases were searched for studies investigating antiplatelet regimens after CABG from inception until April 1, 2019. Studies which randomly assigned CABG patients to either ticagrelor-based or control antiplatelet regimens were eligible. The primary outcome of this analysis was all-cause death. The main secondary outcome was MI. Other outcomes of interest were cardiac death, major adverse cardiac events, stroke and bleeding. This study is registered with PROSPERO, number CRD42019122192.
Results:
Five trials comprising 3996 patients (2002 assigned to ticagrelor-based and 1994 to control antiplatelet regimens) were eligible for quantitative synthesis. The median follow-up was 12 months. Control antiplatelet regimens consisted of either aspirin or clopidogrel or both. As compared to control, ticagrelor-based regimens reduced the risk of all-cause death [0.61 (0.43-0.87); P = 0.007], cardiac death [0.58 (0.39-0.86); P = 0.007] and major adverse cardiac events [0.79 (0.63-0.98); P = 0.03], without difference in the risk of MI [0.76 (0.50-1.18); P = 0.22], stroke [0.99 (0.56-1.78); P = 0.98] or bleeding [1.04 (0.95-1.14); P = 0.41]. There was a treatment effect modification for the primary outcome associated with trials enrolling predominantly patients with acute coronary syndrome (P for interaction = 0.038).
Conclusions:
In patients receiving CABG, ticagrelor-based regimens reduce mortality and major adverse cardiac events without excess bleeding risk as compared with aspirin monotherapy or the combination of aspirin and clopidogrel. The benefit of ticagrelor-based regimens is more relevant in those studies enrolling predominantly patients with acute coronary syndrome. These findings require further confirmation in randomized trials focused on this subset of patients and powered for clinical outcomes.
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