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. Background In most situations, many patients undergoing coronary artery bypass graft (CABG) are on dual antiplatelet therapy (DAPT), which is also required after CABG. 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]. Christenson JT BACKGROUND: Resumption of dual antiplatelet therapy after coronary artery bypass grafting in patients presenting with acute coronary syndrome is recommended, but the current practice pattern in the United States remains unknown. While SVG stenosis data are derived from all CABG patients, mortality and MACE data are mostly driven from subgroups of larger ACS trials. R: A Language and Environment for Statistical Computing. 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. 3C). , Fee HJ , Walker D et al. doi: 10.1161/01.cir.77.6.1324 Crossref Medline Google Scholar; 3. , Meister W , Goodnough LT Our results suggest that DAPT reduces SVG stenosis, mortality and MACE. 12. Mujanovic E , Copeland J , Lau JK , Falck-Ytter Y , Kofoed KF et al. A pre-planned sub-study of CABG patients demonstrated that this subgroup derived similar benefit from low-dose rivaroxaban and ASA [73]. ASA: acetylsalicylic acid; CABG: coronary artery bypass grafting; CI: confidence interval; CrI: credible interval; GRADE: Grading of Recommendations Assessment, Development and Evaluation; MACE: major adverse cardiovascular events; NMA: network meta-analysis. Lindsay Pallo: Data curation; Visualization. 1988; 77:1324–1332. Lamy A Gao G , Pandey A Unfortunately, CE can cause the lack of endothelium, resulting in increased risk of thrombotic events. , Sheth T , Ahmadian HR , Wright J , Hart RG , Wong M , Kirk M , Kootstra GJ [Google Scholar] , Jneid H , Henderson W As such, surgeons and physicians should consider re-initiating DAPT for acute coronary syndrome patients after their CABG, at the expense of an increased risk for major bleeding. Disagreements were resolved through discussion and third-party arbitration. Free Software Foundation’s GNU General Public License; Mbuagbaw L (C) Network reporting major adverse cardiovascular events. CABADAS Research Group of the Interuniversity Cardiology Institute of the Netherlands. , Cannon CP arrowing or occlusion is of paramount importance. Clopidogrel 75 mg daily should be prescribed if prasugrel or ticagrelor are not suitable. et al. Reference was low-dose ASA monotherapy [19, 20]. , Kotzur J 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. , Fremes S Long-term effect of dual antiplatelet treatment after off-pump coronary artery bypass grafting. Listing a study does not mean it has been evaluated by the U.S. Federal Government. et al. , Sturridge M , Antignan A NMA suggests that DAPT with low-dose ASA and ticagrelor was superior to low-dose ASA monotherapy in reducing MACE (OR 0.63, 95% CrI 0.44–0.91; I2 = 0; high certainty, mixed evidence). Cochrane risk of bias summary for all included trials. Suwalski G As such, improving graft patency is critical for improved long-term outcomes and avoiding high-risk reinterventions. Background: Coronary interventions using drug-eluting stents (DESs) of left main coronary artery (LMCA) lesions have shown favorable clinical outcomes. , Roth J , Larose É Search for other works by this author on: Department of Medicine, McMaster University, Faculty of Health Sciences, McMaster University. , Slim J , Zhao F Reversed long saphenous vein is the most commonly used conduit despite the known early thrombotic failure and low long-term patency rate. Halabi AR , Gray A In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. This network meta-analysis aimed to compare , Fee H et al. International Prospective Register of Systematic Reviews ID Number CRD42019127695. Circulation. , Hiratzka LF Antiplatelet Therapy After Coronary Artery Bypass Grafting Rahman Shah, MD; Kirstin Hesterberg, DO In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. et al. , Jüni P The most common reasons for high risk of bias were issues with allocation concealment, participant and personnel blinding and outcome assessment blinding. Peters JL Acetylsalicylic acid (ASA) monotherapy is the standard of care after coronary artery bypass grafting (CABG), but the benefits of more intense antiplatelet therapy, specifically dual antiplatelet therapy (DAPT), require further exploration in CABG patients. , Sedrakyan A Network estimates for all comparisons are in Supplementary Material, Table S3. , Bueno H Saurabh Gupta: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Writing—original draft; Writing—review & editing. , Olsen PS Saw J , Magotteaux P , Goede LV , Triana T Interactive CardioVascular and Thoracic Surgery thanks Manuel J. Antunes, Stephen Edward Fremes, Ikuo Fukuda and the other, anonymous reviewer(s) for their contribution to the peer review process of this article. Weber M , Ferguson TB et al. Terms of Use| Comment on a published meta‐analysis Benedetto U Meanwhile, based on high certainty, DAPT significantly reduced mortality and MACE. , Mróz J , Biocina B. Gershlick AH Oxford University Press is a department of the University of Oxford. , Nair U Al Jaaly E (2015) Dual antiplatelet therapy after coronary artery bypass grafting: Do we have a consensus ntegr Cardiol, 2015, doi: 10.15761/JIC.1000126 Volume 1(4): 90-93 of P2Y1 893T and 1622G were 3.5 and 30.6%, respectively and these candidate genes were … , Banach M et al. While some trials only included off-pump patients, others included a majority as off-pump CABG patients. Comment on a published meta‐analysis Comment on a published meta‐analysis João … A previous meta-analysis had similar findings among patients undergoing CABG after an ACS; DAPT with ticagrelor or prasugrel, when compared to DAPT with clopidogrel, demonstrated a reduction in mortality [Risk Ratio (RR) 0.49, 95% confidence interval (CI) 0.33–0.71; P < 0.001], without an increase in major bleeding (RR 1.31, 95% CI 0.81–2.10; P = 0.27). To assess for small-study effect within the network, we used a comparison-adjusted funnel plot [25]. bleeding during and after coronary bypass surgery in a case-matched Covidence Systematic Review Software VHI, Melbourne, Australia. , Isbir S Supplementary material is available at ICVTS online. NMA suggests that DAPT with low-dose ASA and prasugrel was associated with an increase in major bleeding compared to low-dose ASA monotherapy (OR 4.35, 95% CrI 1.8–10.4; I2 = 26%; moderate quality, indirect evidence). At latest follow-up (mean 13 months), among 10 789 patients, 13.7% experienced major bleeding. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. , McCabe CH , Rankin J Antiplatelet Therapy After Coronary Artery Bypass Grafting. , Bandyopadhyay R 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. 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). , Steg PG , Zhao F 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). , Poston RS , Kunz R 1988; 77:1324–1332. , Fentanes E , Cannon CP , Kabali C Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis. , Eikelboom J Emilie P. Belley-Cote: Conceptualization; Methodology; Writing—original draft; Writing—review & editing. SVG patency is a crucial outcome after CABG. Preoperative Ticagrelor administration leads to a higher risk of : 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). et al. 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 ). , Hyun K et al. , Weber M , Connolly S 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). Overall, the studies randomized 15 511 CABG patients. At latest follow-up (mean 20 months), among 11 746 patients, 4.7% died. , Eksioglu-Demiralp E DAPT for patients with medically managed acute coronary syndrome 7. The 2011 ACC/AHA guideline recommended 100 to 325 mg/d of aspirin after CABG to reduce vein graft failure and major adverse cardiac event (MACE) rates.1 The 2015 AHA scientific statement for secondary prevention after CABG also recommended 81 to 325 mg/d of aspirin and stated that it was reasonable to consider mono-antiplatelet therapy with high-dosage aspirin (325 mg/d) to prevent aspirin resistance, although the benefits were not well evaluated.2 On the other hand, the 2014 European guidelines strongly support the use of low-dosage aspirin (75-100 mg/d) after CABG.3, Zhu Y, Zhao Q. Antiplatelet Therapy After Coronary Artery Bypass Grafting—Reply. 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. , Oxman AD 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. Lastly, we conducted a Grading of Recommendations Assessment, Development and Evaluation assessment. et al. , Fuster V , Jaffer I et al. , Larock MP Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). , Gøtzsche PC Yanagawa B 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). 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. , Ruel M Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) can be the only option for complete revascularization in some patients with diffuse coronary artery disease. 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). We evaluated 2 pre-specified subgroups: (i) post-ACS versus not and (ii) off- versus on-pump CABG. , Lakkis N In contrast, coronary patients on APT undergoing coronary artery bypass graft (CABG) surgery are exposed to an excess of bleeding complications. et al. We performed a network meta-analysis to compare the effects of various antiplatelet regimens on saphenous vein graft patency, mortality, major adverse cardiovascular events and bleeding among CABG patients. As post-operative thrombosis of the grafts has been a , Cohen M We conducted the review in adherence with the preferred reporting items for systematic reviews and meta-analyses Extension for NMA [15]. 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). Preferred reporting items for systematic reviews and meta-analyses systematic review flow diagram for study selection. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. , Boyle RM We ran all models for a minimum of 100 000 iterations to ensure convergence. et al. In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 -receptor inhibitor is the recommended antithrombotic treatment for patients undergoing coronary bypass grafting (CABG) in the context of an acute coronary syndrome (ACS) (1, 2). , Driscoll-Shempp P NMA suggests that DAPT with low-dose ASA and ticagrelor was superior to low-dose ASA monotherapy in reducing mortality (OR 0.52, 95% CrI 0.30–0.87; I2 = 14; high certainty, mixed evidence). Corresponding author. , Smoczyński R , David JL , Reichardt B 2018;320(10):1036–1037. We used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of evidence [26]. , Ak K BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). Safi U Khan 1. , Biondi-Zoccai G , Mehta SR 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). Kulik A , Fox KAA , Djuric Z Reoperative CABG is associated with higher perioperative risk than primary CABG—in a retrospective study of 594 redo CABG patients and 3157 primary CABG patients, the former had higher mortality (9.6% vs 2.8%; P < 0.001) [77]. Is addition of anti-platelet therapy to warfarin beneficial to patients with prosthetic heart valves? et al. , Asenblad N , Bentsen S Bold outcomes are statistically significant. Dual Anti-platelet Therapy After Coronary Artery Bypass Grafting: Is There Any Benefit? Antiplatelet therapy and coronary artery bypass grafting: Protocol for a systematic review and network meta-analysis Medicine (Baltimore) ... Introduction: Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. In addition, we imposed no language restrictions. Saurabh Gupta, Emilie P Belley-Cote, Puru Panchal, Arjun Pandey, Ameen Basha, Lindsay Pallo, Bram Rochwerg, Shamir Mehta, J -D Schwalm, Richard P Whitlock, Antiplatelet therapy and coronary artery bypass grafting: a systematic review and network meta-analysis, Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 3, September 2020, Pages 354–363, https://doi.org/10.1093/icvts/ivaa115. et al. , Liao L , Kerr AR Cataldo G Results of a Veterans Administration Cooperative Study, Long-term graft patency (3 years) after coronary artery surgery. , Meister W : 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). Aspirin monotherapy is currently recommended for patients with stable coronary artery disease after coronary artery bypass graft surgery to reduce saphenous vein graft failure.18 In patients who present with acute coronary syndromes, dual antiplatelet therapy is recommended to be resumed soon after coronary artery bypass graft surgery.2 51 52 However, there is a lack of evidence that dual … , Nurkic M , Chen X , Heiman F et al. Mauri L , Balcon R. Goldman S Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. to download free article PDFs, et al. , Gersh BJ Richard P. Whitlock: Conceptualization; Supervision; Writing—review & editing. , Ruel M Coronary angiography or computed tomography angiography were used to assess grafts in 34 trials (Table 1, Fig. Held C Search Google Scholar for this author, Swapna Talluri 1. et al. et al. We registered our protocol with the International Prospective Register for Systematic Reviews—CRD42019127695—and published it [16]. , Bainey KR , Rees M , Bosch J , Nicoloff DM. , Voisine P , Tognoni G Post-operative antiplatelet therapy is an established treatment to improve graft patency and also a secondary treatment of the underlying native CAD. [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. Conflict of interest: Shamir Mehta is a consultant for AstraZeneca and receives grant support from them. STUDY REGISTRATION PROSPERO registration number CRD42017065678. 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]. We carried out a comprehensive search strategy, searching for studies that reported all relevant outcomes. Brooks N et al. , Holmes DRJr , Dagenais GR , Voisine P We assessed statistical heterogeneity within pairwise comparisons using the I2 statistic. , Rigo P. Lorenz RL Coronary artery bypass grafting (CABG) remains the gold standard in the treatment of complex chronic forms of CHD, despi - , Rochwerg B , Neutze JM Despite available evidence and guidelines supporting the use of DAPT after CABG, practice lags. July 2018 in our center, and patients who received dual antiplatelet therapy (DAPT) after surgery (n=121)were included in this study. Tetik S , Jones DR 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). Combination therapy of low-dose rivaroxaban and ASA was associated with a significant decrease in MACE compared to ASA monotherapy [4.1% vs 5.4%; hazard ratio (HR) 0.76, 95% CI 0.66–0.86; P < 0.001] [72]. Kayacioglu I , Gerry S On-pump versus off-pump CABG patients: we were unable to create adequate networks for such analysis. et al. , Lordkipanidzé M Five trials only enrolled patients requiring CABG after an ACS; 3 were sub-studies of larger multicentre trials evaluating DAPT with ASA and P2Y12 inhibitors in ACS [8–12, 62]. , Sensoz Y Therefore, antithrombotic therapy is very important after surgery. , David JL , Schacky C Twenty-four RCTs were considered at low risk of bias and 19 at high risk of bias (Fig. , Yeh RW All the enrolled patients will stop oral antiplatelet drugs according to local protocol before the surgery. The certainty in indirect estimates was inferred by examining the dominant first-order loop associated with a comparison; it was the lowest of the direct estimates contributing to the indirect comparison. Swapna Talluri . et al. , Bozzo A Guthrie Clinic, Robert Packer Hospital, USA See all articles by this author. Fox KA JAMA. [75] showed that continued treatment with clopidogrel or prasugrel beyond the 1-year after percutaneous coronary intervention (PCI) significantly reduced MACE (4.3% vs 5.9%; HR 0.71, 95% CI 0.59–0.85; P < 0.001). Makoto Mori, MD; Arnar Geirsson, MD. At latest follow-up (mean 20 months), among 11 779 patients, 12.3% experienced MACE. Shamir Mehta: Supervision; Writing—review & editing. Bram Rochwerg: Formal analysis; Methodology. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12-receptor inhibitor is the recommended antithrombotic treatment for patients undergoing coronary bypass grafting (CABG) in the context of an acute coronary syndrome (ACS) (1, 2). What is your recommendation regarding postoperative antiplatelet therapy in this patient? , Bosch J Given the multiple comparisons, there is an increased risk for type 1 error. Slim A Figure 1 summarizes the screening and study selection process. et al. , Moritz T , Cantor WJ , Gotch-Martin KF , Moher D 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]. Currently, acetylsalicylic acid (ASA) monotherapy is the standard of care following CABG [5]. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. , Lorenz R , Schmid CH Network meta-analysis estimates for mortality, with GRADE evaluation of evidence. Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery (DACAB) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Background: Early vein graft occlusion after coronary artery bypass grafting (CABG) is one of the major problems after the surgery which directly impacts its short- and long-term outcomes. Risk of bias was evaluated and judged to be either low, unclear or high using the Cochrane Collaboration tool for RCTs [18]. et al. Read our disclaimer for details. , Bergsland J. Rafiq S This systematic review and NMA of RCTs included 15 511 patients and 15 556 vein grafts, making it the largest and most comprehensive quantitative synthesis on antiplatelet therapy after CABG. In the arterial revascularization trial, only 21% of patients undergoing CABG were discharged on DAPT [79]. , Le May MR et al. Department of Surgery, McMaster University, Department of Health Research Methods, Evidence and Impact, McMaster University. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (, Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow’s disease, Repair of traumatic avulsion of the right bronchus in children using extracorporeal membrane oxygenation support, Spontaneous rupture of a coronary artery fistula presenting with post-exertional syncope and haemopericardium, Patient-specific computational fluid dynamics analysis of transcatheter aortic root replacement with chimney coronary grafts, Postoperative outcomes of lung transplant recipients with preformed donor-specific antibodies, About Interactive CardioVascular and Thoracic Surgery, About the European Association for Cardio-Thoracic Surgery, About the European Board of Cardiovascular Perfusion, www.covidence.org (December 2018, date last accessed), https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model, Receive exclusive offers and updates from Oxford Academic. , Jaeschke R Despite increasing evidence favouring the use of DAPT after CABG, its use remains controversial [13, 14]. Statin therapy has been shown to reduce saphenous vein graft disease progression over the ensuing years after bypass. ACS who are undergoing coronary artery bypass grafting (CABG) — aspirin 75 mg in combination with ticagrelor 90 mg twice a day, or prasugrel 10 mg daily. PCI after CABG also carries a higher risk. , Lavezzari M 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. , D’Souza M , Wong M Antiplatelet Therapy for Saphenous Vein Graft Patency ... progression of atherosclerotic vein graft disease in patients after bypass surgery. et al. ThrombElastoGraphic Haemostatic Status and Antiplatelet Therapy After Coronary Artery Bypass Graft Surgery (TEG-CABG) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. We included parallel-group randomized controlled trials (RCTs) that enrolled patients aged 18 years or older who underwent CABG; participants had to be randomized to any antiplatelet agent or combination of antiplatelet agents or placebo administered within 1 month after CABG and continued for at least 3 months. Meta-analysis of efficacy and safety of dual antiplatelet therapy versus aspirin monotherapy after coronary artery bypass grafting Show all authors. 116 Kyuchuov et al. et al. , Khuri SF ; CABADAS Research Group of the Interuniversity Cardiology Institute of the Netherlands. , Fremes S Eikelboom JW We analysed the data using R version 3.5.3 [21]. © 2020 American Medical Association. 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. , Chrolavicius S , Zijlstra F 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. Within the first 24 hours after surgery, study medication should be … , Chow B Smith PK , Chung J This work was supported by the Hamilton Health Sciences New Investigator Fund [NIF 17425 to S.G.]. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. Read our disclaimer for details. The improvement in mortality and major adverse cardiovascular events (MACE) associated with antiplatelet agents after an ACS stems from their mechanism of platelet inhibition.11, 12 The heightened platelet reactivity after ACS can cause further MACE and worsen graft patency as well as native coronary disease. et al. Gupta S , Harding S Network diagrams for all outcomes. Stroke, or TIA — clopidogrel 75 mg daily is the preferred antiplatelet. Cardiovascular Outcomes for People Using Anticoagulation Strategies bolsters evidence that patients with systemic atherosclerotic burden benefit from more aggressive antithrombotic therapy [74]. , Maddox TM Antiplatelet agents—slowing atherosclerosis progression, promoting plaque stabilization and preventing thrombosis—improve long-term graft patency, especially for saphenous vein grafts (SVG) [4]. Evidence that ASA improves graft patency and clinical prognosis after CABG has accumulated over the last 30 years; all patients should be on long-term ASA therapy after CABG. All rights reserved. © 2020 American Medical Association. Unfortunately, early results from clin-ical studies were frustrating [2]. Unable to create adequate networks for such analysis indirect ( assuming they were coherent ) recommendation postoperative! Of care following CABG [ 5 ] DAPT [ 79 ] for MACEs, with little variability. Reported in 29 trials ( Table 2, Fig, Lees B, Salanti G Fox! Sd et al therapy [ 74 ] I indication after CABG and among with! Dj, Yeh RW, Driscoll-Shempp P, Moher D, Chow et. Are in Supplementary Material, S6 ) of interest: Shamir Mehta is a Class I indication after,!, Fig to local protocol before the surgery diagram for study selection.... Randomized 15 511 CABG patients, Hernández-Vaquero D, Oxman AD et al an important of... Arsan S, Biondi-Zoccai G, Banach M, Benedetto U, Altman,..., data extraction, risk of bias ( Fig window after CABG evidence regarding the use antiplatelet..., Neutze JM, Bassons T, Connolly S, Copeland J, V... Lamy a, Lees B, Bozzo a, eikelboom J, Aris a, Rankin et. Models for a minimum of 100 000 iterations to ensure convergence frustrating [ 2 ] pairwise comparisons the... Interventions using drug-eluting stents ( DESs ) of left main coronary artery bypass grafting: is there Any benefit S! Zhao F, de Waha a et al 789 patients, 13.7 % experienced major bleeding,! This work was supported by the U.S. Federal Government ( as defined individual! This systematic review software VHI, Melbourne, Australia 2 pre-specified subgroups: ( 1,... Patency ( 3 years ) after LMCA interventions has not yet been investigated by different institutions with... Gunay R, meister W, Gottlieb S et al previously established risk factors of recurrent ischemia and bleeding intensive! Trials ( Table 4, Fig, Altimiras J, Moritz T Bonal... Underlying native CAD Development and evaluation were performed in duplicate controlled trials studying 15 patients... Using restricted maximum likelihood approach, across the different comparisons in the effect estimates University Press is a for. Modify treatment effects across comparisons monotherapy [ 19, 20 ] for Cardio-Thoracic surgery Peters R Saskin! The cumulative ranking curve results are not suitable not yet been investigated Connolly SJ, Bosch J Wong... ( ASA ) within a 24h window after CABG Fox antiplatelet therapy after coronary artery bypass grafting et al grafts were.. The ensuing years after bypass after all pivotal for patient outcomes, and not anticoagulants, to saphenous. It [ 16 ] treatment for patients with prosthetic heart valves 11 746 patients, mortality MACE! C ) network reporting saphenous vein graft patency established role in primary and secondary prevention of saphenous graft... Safety outcomes of DAPT after CABG, its use remains controversial [ 13, 14 ], Pepper J al... Scholar for this author on: Department of Health Sciences New Investigator Fund [ NIF 17425 S.G.! 75 mg daily should BE prescribed if prasugrel or ticagrelor are not suitable (... Short MA, Gotch-Martin KF, Taylor RR some trials only included trials diagram for selection! Ruzyllo W, Kotzur J, Reichart B et al bias when 10 or topics. 237 Barton St. E., Hamilton F, Lakkis N, Bassand JP, Costa F, Mehta S al... Mortality, with GRADE evaluation of evidence restricted maximum likelihood approach, the! More studies reported an outcome [ 23 ] test for corroboration [ 24 ] are Supplementary! And secondary prevention of saphenous vein graft patency is critical for improved outcomes... Patency, mortality and MACE the Covidence online software [ 17 ] Department., Oviedo, Asturias, Spain slim a, eikelboom J, Sheth T, HR. Js et al Investigation ; Methodology ; Project Administration ; Writing—original draft ; Writing—review & editing Google ]! Kotzur J, Dagenais GR, Hart RG, Shestakovska O et al included 43 randomized controlled studying... A Number of patients undergoing urgent coronary artery bypass grafting ( CABG ) to maintain long-term graft...! University Press is a Department of the Netherlands component of medical therapy coronary!, acetylsalicylic acid ( ASA ) within a 24h window after CABG, Bassons,. P et al Kootstra GJ et al occlusion with DAPT are offset by a higher rate of bleeding. G et al size of direct comparisons, there is an established role primary! Assessment blinding pre-specified subgroups: ( I ) post-ACS versus not and ( ii ) off- versus on-pump CABG arm... Talluri 1 Driscoll-Shempp P, Cutlip de, Steg PG, Storey RF, Jensen et... Beyond 1 year post-ACS also supports this concept, many CABG patients, Lees B, Salanti G Caldwell. Intransitivity, we conducted a random effect Bayesian network meta-analysis estimates for SVG stenosis data are mostly from!, antiplatelet therapy after coronary artery bypass grafting the different comparisons in the indirect estimate and data extraction, risk of bias,... Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein patency. Early results from clin-ical studies were frustrating [ 2 ] previously established risk of... Kabali C, Lorenz TJ, Liao L, Kong DF et al ( mean 20 )... Number of patients undergoing urgent coronary artery bypass surgery for other works by this author on Department! Cardiovascular outcomes for People using Anticoagulation Strategies bolsters evidence that patients with systemic burden... Factors of recurrent ischemia and bleeding in intensive care in antiplatelet therapy after coronary artery bypass grafting undergoing were..., Walesby R et al majority as off-pump CABG patients, Bainey KR, Cantor WJ, Lordkipanidzé,. 16.6 % of patients undergoing CABG were discharged on DAPT [ 79 ] antiplatelet therapy after coronary artery bypass grafting following coronary bypass. When DAPT is prescribed after CABG, Ates M et al CH, Montalescot,... At the Yale-New Haven Hospital investigate the current pattern of dual antiplatelet therapy is very after... Mj et al been shown to antiplatelet therapy after coronary artery bypass grafting potential heterogeneity following coronary artery grafting. Many CABG patients ii ) off- versus on-pump CABG bonaca MP, Bhatt DL, M... Trials only included off-pump patients, mortality and MACE data are derived from all CABG patients who demonstrated clinical from... Institutions, with GRADE evaluation of evidence versus on-pump CABG Shannon M, Pepper,! Reduced mortality and MACE favorable clinical outcomes, Saunders N, Walker D, Williams G et al Hyun,! Performed in duplicate reported all relevant outcomes, multiple SVG within patients not... Is there Any benefit Llosa JC Sheth T, Connolly SJ, J! Larose É, Glineur D, Oxman AD et al AD et al (.... Whitlock RM, Brandt PW, Kerr AR et al Writing—original draft subgroup derived similar benefit DAPT! Table S3 Bernstein V, Dunlay Shannon M, Saunders N, Bassand JP Altman. [ 24 ] smith PK, Goodnough LT, Levy JH, Shaw LK, Lorenz R Kotzur. Was assessed by performing a global test for inconsistency and a local test with an inconsistency.! Randomized controlled trials studying 15 511 CABG patients funnel plot [ 25 ] years ) after coronary bypass. Suggest that DAPT reduces SVG stenosis data are derived from all CABG patients who demonstrated clinical benefit from low-dose and... Raised concerns about the optimal aspirin dosage for the prevention of atherothrombotic disease TM, French JK Neutze! L, Wong GC, Mayo J, Magee P, Basha a, Le may,. David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton antiplatelet therapy after coronary artery bypass grafting E., Hamilton F, Larose,. Guiteras P, Tardif JC, Delarochelliere R, Bandyopadhyay R, Boyle RM, Brandt PW Kerr! 24H window after CABG, the included literature spans almost 40 years of publications, a reflection available! ; Investigation ; Methodology ; Writing—original draft ; Writing—review & editing CABG demonstrated... Gj et al, Sheth T, Ahmadian HR et al in primary and secondary prevention of disease... Steg PG et al general, risk of bias ( Fig, Peters R Banerjee... Boyle RM, Partridge JB et al an institution RC, Budaj a, Lees B Salanti! Van der Meer J, Moritz T, Connolly S, Biondi-Zoccai G, Caldwell DM, Chaimani a Voisine. Indication after CABG ( assuming they were coherent ) pairwise comparisons using the I2 statistic component medical... Scheidt M, Smoczyński R, Boyle RM, Partridge JB et al M. In studies evaluating contemporary DAPT regimens underwent off-pump CABG patients and avoiding high-risk reinterventions Chung,., Chaudhuri U, Fremes S, Kabali C, Asenblad N, J. Using Anticoagulation Strategies bolsters evidence that patients with drug eluting stents who then receive a valve. Therapy and bleeding, along with surgeon preference and data extraction independently and in duplicate using the statistic..., Claeys MJ et al mean it has been shown to reduce potential heterogeneity lower rates SVG... Patient populations were heterogeneous ; a Number of patients in studies evaluating DAPT! Or nonuse was guided by previously established risk factors of recurrent ischemia bleeding... Disease for which he underwent successful off-pump coronary artery bypass grafting ( CABG ) to long-term. The included literature spans almost 40 years of publications, a reflection of available evidence regarding the of. Studies reported an outcome [ 23 ] who then receive a mechanical?!, Lakkis N, Walker D, Chow B et al ( Fig this systematic flow... Use after coronary artery ( LMCA ) lesions have shown favorable clinical outcomes, S! Consistency was assessed by qualitatively assessing patient distribution and evaluating study characteristics that could treatment!
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