Ticagrelor after CABG associated with a decreased risk of vein graft failure compared to aspirin

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Sigrid Sandner

In patients undergoing coronary artery bypass graft (CABG) surgery, the addition of ticagrelor to aspirin was associated with a significantly decreased risk of vein graft failure, but was accompanied by an increased risk of clinically important bleeding, the findings of a systematic review and meta-analysis of four randomised clinical trials has shown. 

Findings of the analysis were presented during a late-breaking clinical trials session at the 2022 European Association of Cardio-Thoracic Surgery (EACTS) annual meeting (5–8 October, Milan Italy) by Sigrid Sandner (Medical University of Vienna, Vienna, Austria) and published in the Journal of the American Medical Association (JAMA) 

“As we know, early saphenous vein graft failure is mainly due to thrombosis subsequent to endothelial damage, and we also know that inhibition of platelet aggregation with aspirin reduces saphenous vein graft failure,” Sandner said at EACTS 2022, introducing her presentation of the findings of the study. Dual antiplatelet therapy (DAPT) is associated with enhanced platelet inhibitory effects, she noted in the presentation, adding that controversy exists as to the benefit of DAPT for patients after CABG. Studies comparing ticagrelor DAPT with aspirin have yield conflicting results, Sandner said. 

In order to compare the risks of vein graft failure and bleeding associated with ticagrelor DAPT or ticagrelor monotherapy versus aspirin among patients undergoing CABG, Sandner and colleagues, including Mario Gaudino (Weill Cornell Medicine, New York, USA) tapped data from four randomised trials comparing the strategies, with individual patient data from each trial synthesised into a combined data set for independent analysis. 

The primary endpoint of the analysis was the incidence of saphenous vein graft failure per graft, while secondary outcomes were saphenous vein graft failure per patient and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding events. A supplementary analysis included randomised trials comparing ticagrelor monotherapy with aspirin. 

The four trials included 1,316 patients and 1,668 saphenous vein grafts. Of the 871 patients in the primary analysis, 435 received ticagrelor DAPT and 436 received aspirin.  

The investigators found that ticagrelor DAPT was associated with a significantly lower incidence of saphenous vein graft failure (11.2%) per graft than was aspirin (20%) and was associated with a significantly lower incidence of saphenous vein graft failure per patient (13.2% vs 23%).  

Ticagrelor DAPT (22.3%) was associated with a significantly higher incidence of BARC type 2, 3, or 5 bleeding events than was aspirin (8.7%), but not BARC type 3 or 5 bleeding events (1.8% vs 1.8%).  


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