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Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial
Yunpeng Zhu1, Wei Zhang2, Arnaldo Dimagli3
1Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
Insights
Dual antiplatelet therapy with ticagrelor and aspirin for one year after coronary artery bypass grafting significantly reduced major adverse cardiovascular events at five years compared to monotherapy. This finding supports enhanced antiplatelet strategies post-surgery.
Area of Science:
- Cardiovascular Medicine
- Clinical Trials
- Pharmacology
Background:
- Coronary artery bypass grafting (CABG) is a common procedure for severe coronary artery disease.
- Optimizing antiplatelet therapy post-CABG is crucial for preventing adverse cardiovascular events.
- Current guidelines vary on the optimal antiplatelet strategy following CABG.
Purpose of the Study:
- To evaluate the long-term clinical outcomes of different antiplatelet strategies after CABG.
- To compare the efficacy of dual antiplatelet therapy (ticagrelor plus aspirin) versus monotherapy (ticagrelor or aspirin) in preventing major adverse cardiovascular events.
Main Methods:
- A randomized controlled trial (DACAB trial) involving 500 patients undergoing elective CABG.
- Patients were assigned to ticagrelor plus aspirin, ticagrelor monotherapy, or aspirin monotherapy for one year.
- Primary outcome was major adverse cardiovascular events (MACE) assessed over a five-year follow-up period.
Main Results:
- Five-year follow-up data from 477 patients were analyzed.
- Dual antiplatelet therapy significantly reduced MACE compared to aspirin monotherapy (22.6% vs. 29.9%) and ticagrelor monotherapy (22.6% vs. 32.9%).
- Results were consistent across sensitivity analyses, confirming the robustness of the findings.
Conclusions:
- One year of ticagrelor-based dual antiplatelet therapy after CABG is superior to monotherapy in reducing long-term cardiovascular events.
- These findings suggest a potential benefit of intensified antiplatelet treatment in high-risk patients post-CABG.
Objective:
To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting.
Design:
Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial.
Setting:
Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021.
Participants:
500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial.
Interventions:
Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians.
Main Outcome Measures:
The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings.
Results:
Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses.
Conclusions:
Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy.
Trial Registration:
NCT03987373ClinicalTrials.gov NCT03987373.
