Related Experiment Video
Updated: Jul 17, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Optimal antiplatelet strategy following coronary artery bypass grafting: a meta-analysis
Ankit Agrawal1, Ashwin Kumar1, Muhammad Majid1
1Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) reduces mortality and major adverse cardiac events but increases bleeding risk compared to single antiplatelet therapy (SAPT). DAPT with ticagrelor or prasugrel (DAPT-T/P) further lowers mortality compared to clopidogrel (DAPT-C).
Area of Science:
- Cardiology
- Vascular Surgery
- Pharmacology
Background:
- Coronary artery bypass grafting (CABG) is a standard treatment for complex coronary artery disease.
- Aspirin is commonly used post-CABG, but optimal antiplatelet strategies are debated.
- Different dual antiplatelet therapy (DAPT) regimens exist, including those with clopidogrel (DAPT-C) versus ticagrelor or prasugrel (DAPT-T/P).
Purpose of the Study:
- To evaluate the efficacy and safety of different antiplatelet regimens after CABG.
- To compare dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT).
- To compare DAPT with ticagrelor/prasugrel (DAPT-T/P) versus clopidogrel (DAPT-C).
Main Methods:
- Systematic review and meta-analysis following PRISMA guidelines.
- Literature search across major databases (PubMed, Embase, Cochrane).
- Inclusion of 38 studies with 77,447 CABG patients; data pooled using random-effects models.
Main Results:
- DAPT significantly reduced all-cause mortality, cardiovascular mortality, and major adverse cardiac and cerebrovascular events (MACCE) compared to SAPT.
- DAPT was associated with increased rates of major and minor bleeding compared to SAPT.
- DAPT-T/P significantly reduced all-cause and cardiovascular mortality compared to DAPT-C, with no significant differences in other outcomes.
Conclusions:
- DAPT improves survival and reduces MACCE post-CABG, particularly in acute coronary syndrome patients, but increases bleeding risk.
- DAPT-T/P offers superior mortality reduction compared to DAPT-C.
- Individualized antiplatelet therapy selection is crucial, balancing ischemic and bleeding risks in CABG patients.
Objective:
Coronary artery bypass grafting (CABG) is an established revascularisation strategy for multivessel and left main coronary artery disease. Although aspirin is routinely recommended for patients with CABG, the optimal antiplatelet regimen after CABG remains unclear. We evaluated the efficacies and risks of different antiplatelet regimens (dual (DAPT) versus single (SAPT), and dual with clopidogrel (DAPT-C) versus dual with ticagrelor or prasugrel (DAPT-T/P)) after CABG.
Methods:
We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and performed a comprehensive literature search using PubMed, Ovid Medline, Ovid Embase and Cochrane Central Register of Controlled Trials. Data were extracted and pooled using random-effects models and Review Manager (V.5.4).
Results:
Among the 2970 article abstracts screened, 215 full-text articles were reviewed and 38 studies totaling 77 447 CABG patients were included for analyses. DAPT compared with SAPT was associated with significantly lower all-cause mortality (OR 0.65 with 95% CI 0.50 to 0.86; p=0.002), cardiovascular mortality (OR 0.53, 95% CI 0.33 to 0.84; p=0.008), and major adverse cardiac and cerebrovascular events (MACCE) (OR 0.68, 95% CI 0.51 to 0.91; p=0.01), but higher rates of major (OR 1.30, 95% CI 1.08 to 1.56; p=0.007) and minor bleeding (OR 1.87, 95% CI 1.28 to 2.74; p=0.001) after CABG. DAPT-T/P compared with DAPT-C was associated with significantly lower all-cause (OR 0.43, 95% CI 0.29 to 0.65; p≤0.0001) and cardiovascular mortality (OR 0.44, 95% CI 0.24 to 0.80; p=0.008), and no differences on other cardiovascular or bleeding outcomes after CABG.
Conclusion:
In patients with CABG, DAPT compared with SAPT and DAPT-T/P compared with DAPT-C were associated with reduction in all-cause and cardiovascular mortality, especially in patients with acute coronary syndrome. Additionally, DAPT was associated with reduction in MACCE, but higher rates of major and minor bleeding. An individualised approach to choosing antiplatelet regimen is necessary for patients with CABG based on ischaemic and bleeding risks.
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...
01:27Coronary Artery Disease V: Interprofessional Care
01:26Angina IV: Management
01:27Peripheral Artery Disease III: Interprofessional Care
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:26Atherosclerosis III: Management