Safety Comparison of Monotherapy Aspirin to Dual Antiplatelet Therapy Following Coronary Artery Bypass Surgery
Ontology highlight
ABSTRACT: Background
Dual antiplatelet therapy (DAPT) is recommended over single antiplatelet
SUBMITTER: Nei S
PROVIDER: S-EPMC9478706 | biostudies-literature | 2022 Jan
REPOSITORIES: biostudies-literature
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Project description:Background The optimal antiplatelet therapy after coronary artery bypass grafting remains unclear. We evaluated the association of dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin and clinical outcomes among patients undergoing coronary artery bypass grafting. Methods and Results A total of 18 069 consecutive patients who underwent primary isolated coronary artery bypass grafting between 2013 and 2017 were identified from a contemporary registry, and 10 854 (60.1%) received DAPT with clopidogrel plus aspirin as determined by claimed prescriptions after surgery. Cox regression models with inverse probability of treatment weighting were used to examine the associations between DAPT and outcomes. Patients who received DAPT, compared with those who received aspirin monotherapy, had a lower incidence of a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 6 months (2.9% versus 4.2%; inverse probability of treatment weighting-adjusted hazard ratio [HR], 0.65; 95% CI, 0.55-0.77; P<0.001) as well as death (HR, 0.61; 95% CI, 0.41-0.90), myocardial infarction (HR, 0.55; 95% CI, 0.40-0.74), and stroke (HR, 0.58; 95% CI, 0.46-0.74). The incidence of major bleeding did not differ significantly between the 2 groups (HR, 1.11; 95% CI, 0.69-1.78). Similar results were noted across multiple subgroups as well as when using different analytic methods. Conclusions Among patients undergoing coronary artery bypass grafting, DAPT with clopidogrel plus aspirin as secondary prevention was associated with reduced risk of major adverse cardiovascular and cerebrovascular events within 6 months as compared with aspirin monotherapy, and there was no significant increase in major bleeding.
| S-EPMC8483527 | biostudies-literature
Project description:BackgroundCoronary artery disease remains the dominant cause of mortality in developed countries. While platelets have been recognized to play a pivotal role in atherothrombosis, the ideal antiplatelet regime after coronary artery surgery remains elusive. The evolution of CABG has presently moved beyond technical improvements to involve modulation of pharmacologic management designed to improve patient outcomes. The aim of this trial will be to test the hypothesis that the addition of clopidogrel to patients with documented postoperative aspirin resistance will reduce the incidence of major cardiovascular events.MethodsPatients scheduled for isolated coronary artery surgery will be eligible for the study. Patients in whom postoperative multiple electrode aggregometry documents aspirin resistance will be randomized into two groups. The control group will receive 300 mg of aspirin. The dual antiplatelet group will receive 75 mg of clopidogrel in addition to 300 mg of aspirin. Patients will be followed for 6 months. Major adverse cardiac and cerebrovascular events (death from any cause, myocardial infarction, stroke, hospitalization due to cardiovascular pathology) as well as bleeding events will be recorded.DiscussionThis will be the first trial that will specifically address the issue of dual antiplatelet therapy in patients undergoing coronary artery surgery who have been found to be aspirin resistant. In the event that the addition of clopidogrel proves to be beneficial in this subset of surgical patients, this study could significantly impact their future antiplatelet management. This randomized controlled trial has been registered at the ClinicalTrials.gov website (Identifier NCT01159639).
| S-EPMC3502596 | biostudies-literature
Project description:We assessed the effectiveness of dual antiplatelet therapy (DAPT) post elective or urgent (i.e., post acute coronary syndrome [ACS]) coronary artery bypass graft surgery (CABG).We systematically searched MEDLINE, EMBASE, and the Cochrane Registry from inception to August 2015. Randomized controlled trials (RCTs) in adults undergoing CABG comparing either dual vs. single antiplatelet therapy or higher- vs. lower-intensity DAPT were identified.Nine RCTs (n?=?4,887) with up to 1y follow-up were included. Five RCTs enrolled patients post-elective CABG (n?=?986). Two multi-centre RCTs enrolled ACS patients who subsequently underwent CABG (n?=?2,155). These 7 RCTs compared clopidogrel plus aspirin to aspirin alone. Two other multi-centre RCTs reported on ACS patients who subsequently underwent CABG comparing higher intensity DAPT with either ticagrelor (n?=?1,261) or prasugrel (n?=?485) plus aspirin to clopidogrel plus aspirin. Post-operative anti-platelet therapy was started when chest tube bleeding was no longer significant, typically within 24-48 h. There were no differences in all-cause mortality in clopidogrel plus aspirin vs. aspirin RCTs; conversely, all-cause mortality was significantly lower in ticagrelor and prasugrel vs. clopidogrel RCTs (risk ratio[RR] 0.49, 95% confidence interval[CI] 0.33-0.71, p?=?0.0002; 2 RCTs, n?=?1695; I(2) ?=?0%; interaction p?<?0.01 compared to clopidogrel plus aspirin vs aspirin RCTs). There were no differences in myocardial infarctions, strokes, or composite outcomes. Overall, major bleeding was not significantly increased (RR 1.31, 95% CI 0.81-2.10, p?=?0.27; 7 RCTs, n?=?4500). There was heterogeneity (I(2) ? =?42%) due almost entirely to higher bleeding reported for the prasugrel RCT which included mainly CABG-related major bleeding (RR 3.15, 95% CI 1.45-6.87, p?=?0.004; 1 RCT, n?=?437).Most RCT data for DAPT post CABG is derived from subgroups of ACS patients in DAPT RCTs requiring CABG who resume DAPT post-operatively. Limited RCT data with heterogeneous trial designs suggest that higher intensity (prasugrel or ticagrelor) but not lower intensity (clopidogrel) DAPT is associated with an approximate 50% lower mortality in ACS patients who underwent CABG based on post-randomization subsets from single RCTs. Large prospective RCTs evaluating the use of DAPT post-CABG are warranted to provide more definitive guidance for clinicians.
| S-EPMC4605093 | biostudies-other
Project description:Background-Coronary endarterectomy (CEA) has been introduced to allow revascularization in end-stage coronary artery disease (CAD). After CEA, the injured remnants of the vessel's media could result in fast neo intimal tissue ingrowth, which require an anti-proliferation agent (antiplatelet therapy (APT). We aimed to review outcomes of patients undergoing CEA within bypass surgery who received either single-APT (SAPT) or dual-APT (DAPT). Methods-We retrospectively evaluated 353 consecutive patients undergoing CEA within isolated coronary artery bypass grafting (CABG) in the period 01/2000-07/2019. After surgery, patients received either SAPT (n = 153), or DAPT (n = 200) for six months then lifelong SAPT. Endpoints included early, late survival, and freedom from major-adverse-cardiac and cerebrovascular events (MACCE), which were defined as incidence of stroke, myocardial infarction, need for coronary intervention (PCI or CABG) or death for any cause. Results-Patients' mean age was 67 ± 9.3 years; they were predominantly male 88.1%. Both DAPT- and SAPT-groups had the same extent of CAD (mean SYNTAX-Score-II: 34.1 ± 11.6 vs. 34.4 ± 17.2, p = 0.91). Postoperatively, no difference between DAPT- and SAPT-groups was reported in the incidence of low-cardiac-output syndrome (5% vs. 9.8%, p = 0.16), revision for bleeding (5% vs. 6.5% p = 0.64), 30-day mortality (4.5% vs. 5.2%, p = 0.8) or MACCE (7.5% vs. 11.8%, p = 0.19). Imaging follow-up reported significantly higher CEA and total grafts patency (90% vs. 81.5% and 95% vs. 81%, p = 0.017) in DAPT patients. Late outcomes within 97.4 ± 67.4 months show lower incidence of overall mortality (19 vs. 51%, p < 0.001) and MACCE (24.5 vs. 58.2%, p < 0.001) in the DAPT patients when compared with SAPT patients. Conclusions-Coronary endarterectomy allows revascularization in end-stage CAD when the myocardium is still viable. The use of dual APT after CEA for at least six months seems to improve mid-to-long-term patency rates and survival, and reduced the incidence of major adverse cardiac and cerebrovascular events.
| S-EPMC10051999 | biostudies-literature
Project description:ImportanceGuidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.ObjectiveTo compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.Design, setting, and participantsThis cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.ExposuresPostoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.Main outcomes and measuresMajor adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.ResultsA total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results.Conclusions and relevanceIn patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
| S-EPMC8391102 | biostudies-literature
Project description:Unfractionated heparin (UFH) is an effective antithrombotic during surgery but has known adverse effects, in particular on platelets. A marked increase in platelet responsiveness has previously been observed in patients within minutes of receiving UFH, despite adequate inhibition by aspirin prior to heparin. We studied this phenomenon in patients undergoing cardiac artery bypass grafting (n = 17) to determine whether the effects of heparin were systemic or platelet-specific. All patients' platelets were fully inhibited by aspirin prior to surgery, but within 3 min of receiving heparin spontaneous aggregation and responses to arachidonic acid (AA) and ADP increased significantly (p ≥ 0.0002), and activated platelets were found in the circulation. While there was no rise in thromboxane in the plasma following heparin, levels of the major platelet 12-lipoxygenase product, 12-HETE, rose significantly. Mixing experiments demonstrated that the changes caused by heparin resided primarily in the platelets, while addition of AA pathway inhibitors, and analysis of oxylipins provided evidence that, following heparin, aggregating platelets regained their ability to synthesise thromboxane. These findings highlight potentially unrecognised pro-thrombotic and pro-inflammatory changes during CABG surgery, and provide further evidence of adverse effects associated with UFH.
| S-EPMC11015001 | biostudies-literature
Project description:BackgroundWhile coronary artery bypass grafting (CABG) surgery is effective in reducing the risk of myocardial infarction and subsequent cardiac events by improving myocardial perfusion, the risk of sudden cardiac death (SCD) remains notable.MethodsThis retrospective observational study evaluated the efficacy of dual antiplatelet therapy (DAPT) in preventing sudden cardiac death (SCD) among patients undergoing CABG surgery at a major U.S. cardiac center (2012-2015). Data was manually extracted from electronic medical records between 23/04/2017 to 30/03/ 2018 and verified for accuracy, with patients categorized into DAPT or aspirin monotherapy groups based on discharge prescriptions.ResultsOf 2,476 patients followed in this post-CABG study, the analysis included 1,005 patients who received aspirin monotherapy (AMT) and 1,458 patients who received dual antiplatelet therapy (DAPT). AMT group had a significantly higher incidence of SCD compared to those on DAPT (3.1% vs 0.8%; OR = 3.831, 95% CI: 1.961-7.519; p < 0.001). The binary regression model indicated that a higher BMI was associated with an increased risk of SCD (HR = 1.064, 95% CI: 1.012-1.118, p = 0.014). However, patients prescribed P2Y12 antagonists (HR = 0.285, 95% CI: 0.135-0.603, p < 0.001), those with a GFR > 60 ml/min (HR = 0.314, 95% CI: 0.158-0.624, p < 0.001), and those with a higher ejection fraction (HR = 0.962, 95% CI: 0.939-0.986, p = 0.002) were less likely to experience SCD following CABG. A 1 kg/m2 increase in BMI is associated with a 6.4% increase in the risk of SCD. Morbidly obese patients with BMI > 35 were more likely to have experienced SCD than those with BMI < 35 (HR = 2.400, 95% CI: 1.204-4,787; p = 0.013). Similarly, patients with EF > 40% had decreased incidence of SCD compared to those with EF < 40% (HR 0.347, 95% CI:0.158-0.763; p = 0.008). Patients on AMT had higher all-cause (OR = 2.136, 95% CI 1.502-3.038; p < 0.001) and CV mortality (OR = 3.731, 95% CI 2.233-6.235; p < 0.001) but had lower incidence of major bleeding (by drop in hemoglobin criteria) (OR = 0.704, 95% CI: 0.595-0.833; p < 0.001) compared to the DAPT group.ConclusionDAPT prescription after CABG improves survival and lowers risk of sudden cardiac death.
| S-EPMC11856524 | biostudies-literature
Project description:BackgroundSaphenous vein graft disease remains a major limitation of coronary artery bypass graft surgery. The process of saphenous vein intimal hyperplasia begins just days after surgical revascularization, setting the stage for graft atherosclerotic disease and its sequalae. Clopidogrel improves outcomes in patients with atherosclerotic disease, and is effective at reducing intimal hyperplasia in animal models of thrombosis. Therefore, the goal of this study will be to evaluate the efficacy of clopidogrel and aspirin therapy versus aspirin alone in the prevention of saphenous vein graft intimal hyperplasia following coronary artery bypass surgery.MethodsPatients undergoing multi-vessel coronary artery bypass grafting and in whom at least two saphenous vein grafts will be used are eligible for the study. Patients will be randomized to receive daily clopidogrel 75 mg or placebo, in addition to daily aspirin 162 mg, for a one year duration starting on the day of surgery (as soon as postoperative bleeding has been excluded). At the end of one year, all patients will undergo coronary angiography and intravascular ultrasound assessment of one saphenous vein graft as selected by randomization. The trial will be powered to test the hypothesis that clopidogrel and aspirin will reduce vein graft intimal hyperplasia by 20% compared to aspirin alone at one year following bypass surgery.DiscussionThis trial is the first prospective human study that will address the question of whether clopidogrel therapy improves outcomes and reduces saphenous vein graft intimal hyperplasia following cardiac surgery. Should the combination of clopidogrel and aspirin reduce the process of vein graft intimal hyperplasia, the results of this study will help redefine modern antiplatelet management of coronary artery bypass patients.
| S-EPMC1282584 | biostudies-literature
Project description:Background and objectivesAspirin plays an important role in the maintenance of graft patency and the prevention of thrombotic event after coronary artery bypass graft surgery (CABG). However, the use of preoperative aspirin is still under debate due to the risk of bleeding.MethodsFrom PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, data were extracted by 2 independent reviewers. Meta-analysis using random effect model was performed.ResultsWe performed a systemic meta-analysis of 17 studies (12 randomized controlled studies and 5 non-randomized registries) which compared clinical outcomes of 9,101 patients who underwent CABG with or without preoperative aspirin administration. Preoperative aspirin increased chest tube drainage (weighted mean difference 177.4 mL, 95% confidence interval [CI], 41.3-313.4; p=0.011). However, the risk of re-operation for bleeding was not different between the preoperative aspirin group and the control group (3.2% vs. 2.4%; odds ratio [OR], 1.23; 95% CI, 0.94-1.60; p=0.102). There was no difference in the rates of all-cause mortality (1.6% vs. 1.5%; OR, 0.98; 95% CI, 0.64-1.49; p=0.920) and myocardial infarction (MI) (8.7% vs. 10.4%; OR, 0.83; 95% CI, 0.66-1.04; p=0.102) between patients with and without preoperative aspirin administration.ConclusionsAlthough aspirin increased the amount of chest tube drainage, it was not associated with increased risk of re-operation for bleeding. In addition, the risks of early postoperative all-cause mortality and MI were not reduced by using preoperative aspirin.
| S-EPMC6554592 | biostudies-literature
Project description:Acute coronary syndrome (ACS) is principally driven by platelet aggregation. Dual antiplatelet therapy (DAPT) has demonstrated a reduction in recurrent ischemic events. The newer antiplatelets ticagrelor and prasugrel have demonstrated superiority over clopidogrel. While prasugrel demonstrated benefit in patients scheduled for percutaneous intervention (PCI), benefits of ticagrelor were seen irrespective of the treatment strategy. Current guidelines recommend the use of DAPT for 1 year in all patients with ACS. Ticagrelor 60 mg is recommended for up to 3 years in high-risk patients. DAPT and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE DAPT) scores are tools to support decision-making in deciding duration of dual antiplatelet therapy.
| S-EPMC7584687 | biostudies-literature