Related Experiment Video
Updated: Sep 2, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Association of Dual Antiplatelet Therapy With Ticagrelor With Vein Graft Failure After Coronary Artery Bypass Graft
Sigrid Sandner1,2, Björn Redfors3, Dominick J Angiolillo4
1Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
Insights
Ticagrelor dual antiplatelet therapy (DAPT) significantly reduced vein graft failure after coronary artery bypass graft surgery but increased bleeding risk compared to aspirin alone. Ticagrelor monotherapy showed no significant difference.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
- Clinical Trials
Background:
- The optimal antiplatelet strategy after coronary artery bypass graft (CABG) surgery is not well-defined.
- Ticagrelor, with or without aspirin, is being considered, but its efficacy and safety in this context require clarification.
Purpose of the Study:
- To compare the incidence of saphenous vein graft failure and bleeding events.
- To evaluate ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy against aspirin in patients undergoing CABG surgery.
Main Methods:
- A meta-analysis of 4 randomized clinical trials (RCTs) involving 1316 patients and 1668 saphenous vein grafts.
- Individual patient data were synthesized using multilevel logistic regression.
- Primary outcome: saphenous vein graft failure per graft; Secondary outcomes: graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events.
Main Results:
- Ticagrelor DAPT significantly reduced saphenous vein graft failure per graft (11.2% vs 20%; OR, 0.51) and per patient (13.2% vs 23.0%; OR, 0.51) compared to aspirin.
- Ticagrelor DAPT was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events (22.1% vs 8.7%; OR, 2.98).
- Ticagrelor monotherapy did not show a significant difference in graft failure or bleeding events compared to aspirin.
Conclusions:
- In patients undergoing CABG surgery, ticagrelor DAPT significantly decreases vein graft failure but increases the risk of clinically important bleeding.
- The findings suggest a trade-off between graft patency and bleeding risk with ticagrelor DAPT post-CABG.
- Ticagrelor monotherapy does not appear to offer significant benefits over aspirin for graft failure or bleeding in this population.
Importance:
The role of ticagrelor with or without aspirin after coronary artery bypass graft surgery remains unclear.
Objective:
To compare the risks of vein graft failure and bleeding associated with ticagrelor dual antiplatelet therapy (DAPT) or ticagrelor monotherapy vs aspirin among patients undergoing coronary artery bypass graft surgery.
Data Sources:
MEDLINE, Embase, and Cochrane Library databases from inception to June 1, 2022, without language restriction.
Study Selection:
Randomized clinical trials (RCTs) comparing the effects of ticagrelor DAPT or ticagrelor monotherapy vs aspirin on saphenous vein graft failure.
Data Extraction And Synthesis:
Individual patient data provided by each trial were synthesized into a combined data set for independent analysis. Multilevel logistic regression models were used.
Main Outcomes And Measures:
The primary analysis assessed the incidence of saphenous vein graft failure per graft (primary outcome) in RCTs comparing ticagrelor DAPT with aspirin. Secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included RCTs comparing ticagrelor monotherapy with aspirin.
Results:
A total of 4 RCTs were included in the meta-analysis, involving 1316 patients and 1668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT (median age, 67 years [IQR, 60-72 years]; 65 women [14.9%]; 370 men [85.1%]) and 436 received aspirin (median age, 66 years [IQR, 61-73 years]; 63 women [14.5%]; 373 men [85.5%]). Ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%; difference, -8.7% [95% CI, -13.5% to -3.9%]; OR, 0.51 [95% CI, 0.35 to 0.74]; P < .001) and was associated with a significantly lower incidence of saphenous vein graft 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 < .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 < .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 = .99). Compared with aspirin, ticagrelor monotherapy was not significantly associated with saphenous vein graft 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 = .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 = .46).
Conclusions And Relevance:
Among patients undergoing coronary artery bypass graft 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.
Related Concept Videos
01:20Antiplatelet Drugs: Prostaglandin Synthesis, P2Y12 and Glycoprotein IIb/IIIa Inhibitors
Prostaglandin synthesis inhibitors, exemplified by the widely known aspirin, wield their power by irreversibly acetylating...
01:29Venous Thrombosis III: Interprofessional Care
01:27Coronary Artery Disease V: Interprofessional Care
01:23Peripheral Artery Disease V: Postoperative Nursing Management
01:27Peripheral Artery Disease III: Interprofessional Care
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...