Ticagrelor and Aspirin or Aspirin Alone after Coronary Surgery for Acute Coronary Syndrome
Anders Jeppsson1,2, Stefan James3, Christian H Moller4
1Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
Insights
Adding ticagrelor to aspirin therapy after coronary-artery bypass grafting (CABG) did not reduce adverse cardiovascular events. The combination therapy also increased the risk of major bleeding compared to aspirin alone.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Antiplatelet therapy is crucial for patients post-coronary-artery bypass grafting (CABG) for acute coronary syndrome.
- The added benefit of ticagrelor to aspirin therapy in this patient population remains unclear.
Purpose of the Study:
- To investigate whether adding ticagrelor to aspirin therapy reduces adverse cardiovascular outcomes after CABG compared to aspirin alone.
Main Methods:
- An open-label, registry-based randomized trial involving 2201 patients undergoing CABG for acute coronary syndrome.
- Patients were assigned to receive ticagrelor plus aspirin or aspirin alone for 1 year.
- The primary outcome was a composite of death, myocardial infarction, stroke, or repeat revascularization.
Main Results:
- No significant difference in the primary outcome was observed between the ticagrelor-plus-aspirin group (4.8%) and the aspirin-alone group (4.6%).
- The ticagrelor-plus-aspirin group had a higher incidence of net adverse clinical events (9.1% vs. 6.4%) and major bleeding (4.9% vs. 2.0%).
Conclusions:
- Ticagrelor plus aspirin did not lower the incidence of major adverse cardiovascular events compared to aspirin alone in patients after CABG for acute coronary syndrome.
- The combination therapy was associated with an increased risk of major bleeding.
Background:
Patients benefit from antiplatelet therapy after coronary-artery bypass grafting (CABG) for an acute coronary syndrome. Whether the addition of ticagrelor to aspirin, as compared with aspirin alone, further reduces the risk of adverse cardiovascular outcomes is unclear.
Methods:
In this open-label, registry-based, clinical trial conducted at 22 Nordic cardiothoracic surgery centers, we randomly assigned patients in a 1:1 ratio to receive either ticagrelor plus aspirin or aspirin alone for 1 year after CABG for an acute coronary syndrome. The primary outcome was a composite of death, myocardial infarction, stroke, or repeat revascularization, evaluated at 1 year. A key secondary outcome was net adverse clinical events, defined as a primary-outcome event or major bleeding.
Results:
A total of 2201 patients were randomly assigned to receive ticagrelor plus aspirin (1104 patients) or aspirin alone (1097 patients). The mean age of the patients was 66 years, and 14.4% were women. A primary-outcome event occurred in 53 patients (4.8%) in the ticagrelor-plus-aspirin group and 50 (4.6%) in the aspirin-alone group (hazard ratio, 1.06; 95% confidence interval [CI], 0.72 to 1.56; P = 0.77). Net adverse clinical events occurred in 9.1% of patients in the ticagrelor-plus-aspirin group and 6.4% in the aspirin-alone group (hazard ratio, 1.45; 95% CI, 1.07 to 1.97). Major bleeding occurred in 4.9% of patients in the ticagrelor-plus-aspirin group and 2.0% in the aspirin-alone group (hazard ratio, 2.50; 95% CI, 1.52 to 4.11).
Conclusions:
Among patients who underwent CABG for an acute coronary syndrome, ticagrelor plus aspirin did not result in a lower incidence of death, myocardial infarction, stroke, or repeat coronary revascularization than aspirin alone at 1 year. (Funded by the Swedish Research Council and others; TACSI ClinicalTrials.gov number, NCT03560310; EudraCT number, 2017-001499-43; EU Clinical Trials number, 2023-508551-40-00.).
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