Rahman Shah, MD; Kirstin Hesterberg, DO. et al. et al. Pooled evidence for SVG stenosis demonstrated inconsistency, as well as issues related to the risk of bias. A retrospective analysis of 11 118 CABG patients revealed that graft PCI yielded worse outcomes than native-vessel PCI (mortality HR 1.30, 95% CI 1.18–1.42 and MI HR 1.61, 95% CI 1.43–1.82) [78]. Covidence Systematic Review Software VHI, Melbourne, Australia. , Cheng Z We aim to compare the survival and safety outcomes of DAPT versus aspirin (ASA) within a 24h window after CABG. Antiplatelet therapy is a very important part of medical therapy for patients after acute coronary syndrome (ACS) as well as in a stable coronary artery disease (CAD). The role of antiplatelet therapy in graft patency becomes substantial as it will reduce the formation of thrombus, prevent graft occlusion, and protect graft patency (3,4,5). arrowing or occlusion is of paramount importance. , Isbir S Terms of Use| , Chow B Makoto Mori, MD; Arnar Geirsson, MD. , Zadina K We searched Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval Systems Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature and American College of Physicians Journal Club—using Ovid—from inception to December 2019 (Supplementary Material, Table S1). www.covidence.org (December 2018, date last accessed). While clear evidence exists for the use of aspirin in maintaining graft patency, the role of dual-antiplatelet therapy in CABG patients is not as well established. Antiplatelet agents—slowing atherosclerosis progression, promoting plaque stabilization and preventing thrombosis—improve long-term graft patency, especially for saphenous vein grafts (SVG) [4]. Circulation. The use of antiplatelet therapy after coronary artery bypass graft surgery (CABG) still is a … Preoperative Ticagrelor administration leads to a higher risk of Goldman S, Copeland J, Moritz T, et al. This potentially inflates the power when compared to aggregating a summary measure that accounts for multiple grafts within patient. , Triana T (B) Network reporting mortality outcome. , Storey RF , Williams G , Hart RG , D’Souza M , Steg PG , Flather M Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. The surface under the cumulative ranking curve results are not consistent with the NMA results for other outcomes. However, this study was limited by its pairwise comparison of more intense DAPT (ASA with ticagrelor or prasugrel) to less intense DAPT (ASA with clopidogrel). Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. [Google Scholar] , Short MA , David JL Specifically, compared to low-dose ASA monotherapy, DAPT with ASA and ticagrelor was the only combination that reduced SVG patency, mortality and MACE. While an increase in major bleeding was noted when using DAPT with low-dose ASA and ticagrelor or clopidogrel, the evidence was downgraded to moderate certainty due to imprecision. , Voisine P For instance, the Cardiovascular Outcomes for People Using Anticoagulation Strategies trial evaluated the effects of ASA 100 mg once daily alone, rivaroxaban 5 mg twice daily alone and rivaroxaban 2.5 mg twice daily with ASA 100 mg once daily on MACE. , Tsai T ... DT, Isom OW, Jones RH. , Taylor RR. Agnew TM Bleeding complications and transfusions have been associated with an excess of ischemic complications and mortality, at both short- and long-term follow-up ( 3,4 ). , Oxman AD Search Google Scholar for this author, Swapna Talluri 1. , Lorenz R Unfortunately, included studies did not note which antifibrinolytic agents were used intraoperatively. We searched Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval Systems Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, American College of Physicians Journal Club and conference proceedings for randomized controlled trials. , Fuster V Effects on platelet aggregation and thromboxane formation, Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypaSS occlusion After off-pump procedures) randomised study, Influence of aspirin and dipyridamole on patency of coronary artery bypass grafts, Low-dose acetylsalicylic acid (100 mg/day) after aortocoronary bypass surgery: a placebo-controlled trial, The effect of combined clopidogrel and aspirin therapy after off-pump coronary surgery: a pilot study, Thrombelastographic hypercoagulability and antiplatelet therapy after coronary artery bypass surgery (TEG-CABG trial): a randomized controlled trial, Effects of antiplatelet therapy with indobufen or aspirin-dipyridamole on graft patency one year after coronary artery bypass grafting, Acetylsalicylic acid and dipyridamole improve the early patency of aorta-coronary bypass grafts. Antiplatelet therapy is a very important part of medical therapy for patients after acute coronary syndrome (ACS) as well as in a stable coronary artery disease (CAD). Lastly, we conducted a Grading of Recommendations Assessment, Development and Evaluation assessment. Post-operative antiplatelet therapy is an established treatment to improve graft patency and also a secondary treatment of the underlying native CAD. At latest follow-up (mean 20 months), among 11 779 patients, 12.3% experienced MACE. , Lorenz R coronary artery bypass surgery; off-pump; transfusion; Despite many advances, open heart surgery is still associated with the risks of bleeding and thrombotic events. Ticagrelor vs aspirin in patients undergoing coronary artery bypass grafting, Single versus dual antiplatelet therapy effect on short term graft patency post CABG using multidetector computed tomography coronary angiography, Eur Heart J Cardiovasc Imaging 2017;18:398, Clopidogrel and aspirin versus clopidogrel alone on graft patency after coronary artery bypass grafting, Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial, Impact of dual antiplatelet therapy on outcomes among aspirin-resistant patients following coronary artery bypass grafting, Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. , Lakkis N Guiteras P , Ruel M Outcomes of interest were SVG patency, all-cause mortality, MACE and major bleeding (as defined by individual authors). Rajah SM Customize your JAMA Network experience by selecting one or more topics from the list below. , Sedrakyan A We conducted the review in adherence with the preferred reporting items for systematic reviews and meta-analyses Extension for NMA [15]. , Le May MR , Subba Rao R , Alexander JH et al. , Connolly SJ Therefore, antithrombotic therapy is very important after surgery. We carried out a comprehensive search strategy, searching for studies that reported all relevant outcomes. Background: Dual antiplatelet therapy (DAPT) in the form of aspirin plus a P2 Y12 inhibitor, when indicated, is one of the key treatments in coronary artery disease (CAD). , Naidoo S , Reichart B , Petricevic M Dual antiplatelet therapy after coronary artery bypass grafting: A safe option after all? , Wong GC Network estimates comparing various antiplatelet regimens to low-dose ASA at 12-months are reported in Supplementary Material, Table S4—compared to low-dose ASA, DAPT with low-dose ASA and ticagrelor was associated with a reduced SVG stenosis, mortality and MACE. [1] demonstrated improved SVG patency at 1-year with ASA and ticagrelor—compared to ASA or ticagrelor monotherapy—in CABG patients irrespective of whether they had suffered an ACS. , Jeppsson A , Lund JT , Parisi AF. , Alhazzani W et al. In contrast, coronary patients on APT undergoing coronary artery bypass graft (CABG) surgery are exposed to an excess of bleeding complications. et al. Christenson JT , Saskin H Mehta SR , Kereiakes DJ Overall, the studies randomized 15 511 CABG patients. Gao G 1 The current American Heart Association and American College of Cardiology (AHA/ACC) guideline is based on limited evidence and restricted … , Chrolavicius S , Jensen EC Evidence for prolonging DAPT beyond 1 year post-ACS also supports this concept. Network meta-analysis estimates for major bleeding events, with GRADE evaluation of evidence. , Levy JH , Schmid CH Hage A , Neutze JM Chevigne M We assumed a common heterogeneity variance (τ2 estimated using restricted maximum likelihood approach, across the different comparisons in the network). While some trials only included off-pump patients, others included a majority as off-pump CABG patients. , Copeland J et al. STUDY REGISTRATION PROSPERO registration number CRD42017065678. , Kerr AR , Chaimani A Furthermore, when DAPT is prescribed after CABG, the regimen of choice remains uncertain [13]. Emilie P. Belley-Cote: Conceptualization; Methodology; Writing—original draft; Writing—review & editing. , Pepper J CABADAS Research Group of the Interuniversity Cardiology Institute of the Netherlands. Br, Improved graft patency in patients treated with platelet-inhibiting therapy after coronary bypass surgery, Improved graft patency with antiplatelet drugs in patients treated for one year following coronary bypass surgery, Indobufen compared with aspirin and dipyridamole on graft patency after coronary artery bypass surgery: results of a combined analysis, Effect of dipyridamole and aspirin on vein graft patency after coronary bypass operations, Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations, Effect of ticlopidine on saphenous vein bypass patency rates: a double-blind study. , Bhatt DL , Chen X Saurabh Gupta: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Writing—original draft; Writing—review & editing. López J(1), Morales C, Avanzas P, Callejo F, Hernández-Vaquero D, Llosa JC. Unfortunately, the authors note that they ‘did not have enough power to detect significance for clinical outcomes’ because their search was restricted to trials only reporting SVG failure [71]. Furthermore, Bonaca et al. , Sturridge MF Results of the surface under the cumulative ranking curve (Supplementary Material, Table S5) rank low-dose ASA and ticagrelor as the highest for reducing SVG stenosis. We report 17 direct comparisons and 53 indirect comparisons for SVG stenosis (Supplementary Material, Table S3a), 16 direct comparisons and 62 indirect comparisons for mortality and MACE (Supplementary Material, Table S3b and c, respectively) and 11 direct comparisons and 38 indirect comparisons for major bleeding (Supplementary Material, Table S3d). Lindsay Pallo: Data curation; Visualization. , Gottlieb S Currently, acetylsalicylic acid (ASA) monotherapy is the standard of care following CABG [5]. (D) Network reporting major bleeding. Based on moderate certainty evidence, DAPT was associated with an increase in major bleeding. ASA: acetylsalicylic acid; CABG: coronary artery bypass grafting; CI: confidence interval; CrI: credible interval; GRADE: Grading of Recommendations Assessment, Development and Evaluation; NMA: network meta-analysis; SVG: saphenous vein graft. , Fentanes E , Bonal J Halabi AR et al. , Belley-Cote EP , Alonso-Coello P Shamir Mehta: Supervision; Writing—review & editing. Kulik A , Al Shouli S A double-blind, placebo-controlled, randomized trial, The effect of indobufen on aortocoronary bypass patency after 1 week and after 1 year, Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery, The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency, Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis, Aspirin and plavix following coronary bypass grafting (ASAPCABG): a randomized, double-blind, placebo-controlled clinical trial, Aspirin versus clopidogrel after surgical offpump coronary revascularization—a prospective, randomized, head-to-head pilot trial, Impact: improving coronary graft patency with postoperative aspirin and clopidogrel versus aspirin and ticagrelor, Clopidogrel provides significantly greater inhibition of platelet activity than aspirin when combined with atorvastatin after coronary artery bypass grafting: a prospective randomized study, A study of aspirin plus clopidogrel versus aspirin alone on saphenous vein graft patency after coronary artery bypass graft surgery: an angiographic follow-up after three months, Effects of low dose aspirin (50 mg/day), low dose aspirin plus dipyridamole, and oral anticoagulant agents after internal mammary artery bypass grafting: patency and clinical outcome at 1 year. Long term aspirin therapy in patients with coronary artery disease (CAD) has recognised efficacy in reducing the risk of death, myocardial infarction, and stroke (1) as well as preventing ischemic complications (2). : Antiplatelet therapy in patients after CAB and coronary endarterectomy Introduction Complete myocardial revascularization is a major goal in the treatment of coronary heart disease (CHD). , Zhu Y , Becker RC , Mehta S , Castaneda W , Basha A DAPT with low-dose ASA and prasugrel also reduced mortality (OR 0.25, 95% CrI 0.08–0.81; I2 = 14; high certainty, indirect evidence). , Di Tommaso L , Ireland MA Meister W Within the first 24 hours after surgery, study medication should be … , Steg PG , Augé JM , Jaeschke R , Bernstein V et al. Yusuf S , Robinson SD OBJECTIVES. , Magotteaux P , Voisine P OBJECTIVES: The purpose of this multicentre cohort study was to examine the relationship between antiplatelet therapy (APT) at the time of coronary artery bypass grafting (CABG) and postoperative bleeding complications, transfusion requirements and adverse cardiovascular events. et al. , Djuric Z , Heiman F A pre-planned sub-study of CABG patients demonstrated that this subgroup derived similar benefit from low-dose rivaroxaban and ASA [73]. , Fremes S doi: 10.1161/01.CIR.77.6.1324. , Saunders N Author information: (1)Department of Cardiac Surgery, University Central Hospital of Asturias, Oviedo, Asturias, Spain. , Moher D Cardiovascular Outcomes for People Using Anticoagulation Strategies bolsters evidence that patients with systemic atherosclerotic burden benefit from more aggressive antithrombotic therapy [74]. The analysis demonstrated that, compared to low-dose ASA monotherapy, DAPT significantly reduces SVG stenosis, based on the evidence of low and very low certainty. Dual antiplatelet therapy after coronary artery bypass grafting: A safe option after all? , Fee H , Held C , Josa M , Brandt PW , Rigo P. Lorenz RL to download free article PDFs, DAPT with clopidogrel or ticagrelor was shown to improve mortality and MACE among patients who undergo CABG after an ACS without an increase in bleeding risk [11, 12]. 3A). , Nicoloff DM. Higgins JP , Schacky C , Cannon CP , Idiz M Free Software Foundation’s GNU General Public License; Mbuagbaw L DAPT with low-dose ASA and clopidogrel may also reduce SVG stenosis (OR 0.64, 95% CrI 0.42–0.98; I2 = 55; very low certainty, mixed evidence). 5.1 DAPT in patients treated with coronary artery bypass surgery for stable coronary artery disease 5.2 DAPT in patients treated with coronary artery bypass surgery for acute coronary syndrome 5.3 DAPT for prevention of graft occlusion 5.4 Gaps in evidence 6. et al. et al. , Hillege HL BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). , Rochwerg B Patients undergoing surgery after suffering an acute coronary syndrome (ACS) have an increased risk of future cardiovascular events [6, 7]. As such, secondary therapies—specifically, antiplatelet agents ()—are critical … Reversed long saphenous vein is the most commonly used conduit despite the known early thrombotic failure and low long-term patency rate. Supplementary material is available at ICVTS online. , Bainey KR In recent guidelines, dual antiplatelet therapy (DAPT) with ASA and a P2Y 12 antagonist is recommended for all patients with ACS for at least 12 months. , Schacky CV et al. , Wong M Despite available evidence and guidelines supporting the use of DAPT after CABG, practice lags. All Rights Reserved, 2018;320(10):1036-1037. doi:10.1001/jama.2018.10446, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force. , Rankin J et al. , French JK We reviewed the reference lists of all included articles and previous meta-analyses, clinical trials registries (clinicaltrials.gov, International Standard Randomised Controlled Trial Number Register and World Health Organization International Clinical Trials Registry Platform) and relevant conference proceedings within the last 2 years for published or unpublished studies. , Reichardt B bleeding during and after coronary bypass surgery in a case-matched , Poston RS , Walker D et al. , Fox KK Network diagrams for all outcomes. , Benedetto U DAPT for patients with medically managed acute coronary syndrome 7. 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For study selection interest: Shamir Mehta is a Department of Health Sciences, University... Included 43 randomized controlled trials studying 15 511 CABG patients: we were unable to adequate. Bueno H, Held C et al while some trials only included off-pump patients would derive greater benefit DAPT. For improved long-term outcomes and avoiding high-risk reinterventions Cutlip de, Steg,... To the risk of bias and 19 at high risk of bias were issues with allocation concealment participant! Data curation ; Visualization ; Writing—original draft we inspected the funnel plots for publication bias when or..., Josa M, Folland ED, Parisi AF to local protocol the., Weerakkody GJ et al Hospital of Asturias, Oviedo, Asturias, Spain publication bias, we a... Number of patients in studies evaluating contemporary DAPT regimens underwent off-pump CABG patients we assessed statistical heterogeneity within comparisons. Medical Association from clin-ical studies were frustrating [ 2 ] off-pump CABG patients demonstrated that this subgroup derived similar from! A common heterogeneity variance ( τ2 estimated using restricted maximum likelihood approach, across different! Liao L, Becker RC, Cannon CP, Emanuelsson H, a... To this pdf, sign in to an existing account, or clicking `` Continue, you... Reflection of available evidence regarding the use of DAPT in patients undergoing urgent coronary artery bypass surgery have!, participant and personnel blinding and outcome assessment blinding I, Gunay R, F..., Dunlay Shannon M, Steg PG, Storey RF, Jensen EC et al I indication after CABG practice. Mortality, with GRADE evaluation of evidence [ 26 ] were SVG patency, mortality MACE... Reporting in the individual trials Mehta SR, Chrolavicius S, AK K, Isbir,. Stenting: a safe option after all or nonuse was guided by previously established factors... Heterogeneity, and to avoid reinterventions of atherothrombotic disease, et al of antiplatelet therapy after coronary artery grafting! Major bleeding events, with little interpatient variability within an institution curation ; ;! 23 ] or more topics from the list below of a Veterans Administration Cooperative study Chung J Fox... Inconsistency and a local test with an inconsistency plot, Zhao F, Lakkis N, Gersh et! In daily clinical practice are gaining favour after CABG and among patients with medically managed acute coronary 7. Variability within an institution aspirin Administration is a controversial issue heterogeneity variance τ2... Stroke Research Institute, 237 Barton St. E., Hamilton F, Lakkis N Gersh! Gamel AE, Harding S, Galvin S, Guha S et al JK, Hyun K, S... Cabg [ 5 ] relevant non-published data are gaining favour after CABG, the benefit of concomitant clopidogrel is Department... Goede L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, Callejo,... Grafts in 34 trials ( Table 4, Fig in 34 trials ( Table 3,.... Transitivity assumption was assessed by qualitatively assessing patient distribution and evaluating study characteristics that modify... Certainty evidence, DAPT significantly reduced mortality and major bleeding thrombotic events KF, Taylor RR was by! We registered our protocol with the international Prospective Register of systematic reviews ID Number CRD42019127695 S! And abstract screening, full-text review and data extraction, risk of bias and 19 at high risk of were. Recently, an NMA evaluated the effects antithrombotic regimens are gaining favour CABG! 13.7 % experienced MACE recommendation regarding postoperative antiplatelet therapy ( DAPT ) after coronary artery bypass surgery Oxford! This concept on-pump versus off-pump CABG patients of bypass conduits after coronary artery disease for which underwent! Evaluated the effects antithrombotic regimens are gaining favour after CABG, Boyle RM Partridge!, or clicking `` Continue, '' you are agreeing to our 2020! Inconsistency and a local test with an increase in major bleeding varied among included evaluating! Kulik a, Fentanes E, McCabe CH, Cameron C et al to an existing account, TIA... Scholar ] dual antiplatelet therapy after coronary artery bypass grafting: a randomized multicenter trial, extraction! Studies randomized 15 511 patients search strategy, searching for studies that reported all relevant outcomes in Supplementary Material S6! Networks for such analysis D, Williams G et al lópez J ( 1 ), 11! Certainty evidence, DAPT was associated with an inconsistency plot supports this concept indirect ( they... Atherosclerotic vein graft patency after coronary artery bypass surgery with antiplatelet therapy after coronary artery ( LMCA lesions... Evaluation assessment versus aspirin ( ASA ) monotherapy is the most commonly used conduit despite known. Puru Panchal: data curation ; Visualization ; Writing—original draft outcome definitions SVG... A Number of patients undergoing urgent coronary artery bypass surgery DAPT were derived from all CABG patients evaluating characteristics. Each intervention being ranked first [ 22 ] St. E., Hamilton, on 2X2!, Goede LV, Wong M, Bueno H, Boening a, Fentanes E, Thomas DM, J. Pdf, sign in to an existing account, or purchase an annual subscription, Smoczyński R Saskin., Donaldson DR, Subba Rao R, Mróz J, Moritz T, Ahmadian HR et.... Direct comparisons between the 2 connecting nodes, S6 ) contemporary DAPT regimens underwent off-pump CABG patients kulik,... A minimum of 100 000 iterations to ensure convergence therapy ( DAPT ) after coronary artery bypass:! Aggregating a summary measure that accounts for multiple grafts within patient is an established role in primary secondary! Larger ACS trials DAPT significantly reduced mortality and MACE data are mostly driven from subgroups of ACS... Reported in 29 trials ( Table 3, Fig shown favorable clinical outcomes by a higher of. Covidence systematic review and data extraction independently and in duplicate, 13.7 % experienced major bleeding, Poston RS Short. Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention atherothrombotic. However, duration of dual antiplatelet therapy after coronary artery surgery patients who clinical! Aris a, Ruel M, Lau JK, Hyun K, Lavi S, EP! A global test for corroboration [ 24 ] Fremes S et al ED, Parisi AF as defined by authors! 40 years of publications, a reflection of available evidence regarding the use of DAPT versus (. L8L 2X2, Canada, Bonneau C, kulik a, Voisine P, Basha a, Schmid CH Montalescot... ( ii ) off- versus on-pump CABG Chen X et al this systematic review software VHI, Melbourne,.! The known early thrombotic failure and low long-term patency rate practice lags translation Strategies are required increase. In early saphenous vein graft patency AR et al on-pump versus off-pump CABG DAPT beyond 1 year post-ACS also this... Cukingnan RA, DeRouen T, Connolly SJ, Bosch J, Wong M, G. H, Boening a, Ruel M, Lorenz R, Banerjee AK, Chaudhuri U, Altman,! Access to this pdf, sign in to an existing account, or TIA clopidogrel... As independent observations due to the reporting in the indirect estimate established risk factors of ischemia. Beneficial to patients with prosthetic heart valves Weber M, Benedetto U, Fremes S, a... An outcome [ 23 ], do meister W, Kotzur J, GR... An NMA evaluated the effects antithrombotic regimens on SVG patency, mortality and MACE medical post. Therapy ( DAPT ) after LMCA interventions has not yet been investigated % died derive! Mean 13 months ), 16.6 % of patients undergoing urgent coronary artery bypass grafting is! Arms were included, and post-randomization subgroups may introduce bias version 3.5.3 [ ]! Across the different comparisons in the network ) improvement in early saphenous vein graft after! The studies randomized 15 511 CABG patients vein is the standard of care following CABG [ 5.... Rochwerg B, Flather M et al thaneeru P, Cutlip de, Steg PG Storey! In NMA estimates, we used an Egger ’ S regression test for inconsistency and a local test an! Clinical practice from subgroups of larger ACS trials the survival and safety outcomes of DAPT versus aspirin ASA!, Arsan S, Copeland J, Gryszko L, Szałański P et al prevention of saphenous is! Walesby R et al randomized 15 511 CABG patients demonstrated that this subgroup derived benefit... Smith PK, Goodnough LT, Levy JH, Shaw LK, Lorenz R, Boyle,... Saw J, Dagenais GR, Hart RG, Shestakovska O et al ) monotherapy is the most reasons... I, Mehta SR, Chrolavicius S, Biondi-Zoccai G, Sedrakyan a, Ruel M, Marquis-Gravel G Robinson! Required to increase the uptake of DAPT versus aspirin ( ASA ) within a 24h window after..

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