Comparison of dual antiplatelet therapies after coronary endarterectomy combined with coronary artery bypass grafting: a cohort study

Ticagrelor vs. clopidogrel in dual antiplatelet therapy after coronary artery bypass surgery: a meta-analysis

Background

Following coronary artery bypass grafting (CABG), the standard treatment regimen typically involves dual antiplatelet therapy (DAPT), which includes a P2Y12 receptor antagonist in combination with aspirin. There is currently no clear consensus regarding the optimal DAPT strategy after CABG. The aim of this meta-analysis was to evaluate and compare the safety and efficacy of ticagrelor vs. clopidogrel in patients post-CABG.

Methods

A meta-analysis of eligible studies of patients undergoing CABG and receiving either aspirin plus clopidogrel (A + C) or aspirin plus ticagrelor (A + T) as antiplatelet therapy, was carried out. The outcomes of interest included all-cause mortality, cardiovascular mortality, major adverse cardiovascular and cerebrovascular events (MACCEs), major bleeding, myocardial infarction, stroke, revascularization, saphenous vein occlusion and total graft occlusion.

Results

4 randomized controlled trials and 3 observational studies (n = 2,424) were eligible for final analysis. A + T was associated with a decreased risk of all-cause mortality (OR = 0.47, 95% CI 0.31-0.70, p < 0.001, p heterogeneity = 0.80, I2 = 0%) and cardiovascular mortality (OR = 0.50, 95% CI 0.31-0.82, p = 0.006, p heterogeneity = 0.71, I2 = 0%), compared with A + C group. No statistically significant difference was found in the rates of major bleeding (OR = 1.16; 95% CI 0.69-1.96; p = 0.57; p heterogeneity = 0.26; I2 = 23%) between two groups. Besides, the rates of MACCEs, myocardial infarction, stroke, total graft occlusion, revascularization and saphenous vein occlusion were comparable between two groups (p > 0.05).

Conclusions

The meta-analysis presented the evidence supporting the use of A + T post-CAVG in reducing all-cause mortality and cardiovascular mortality, with no increase in bleeding events, in comparison with A + C. Additional RCTs are needed to determine the optimal DAPT after CABG.

Predictors of secondary revascularization after coronary artery bypass graft surgery and role of dual antiplatelet therapy

BACKGROUND

Despite advancements in surgical techniques, interventional procedures, novel pharmacotherapies, and other contemporary treatments, patients after coronary artery bypass graft surgery (CABG) remain at risk for graft failure and progression of native vessel disease progression. Consequently, secondary revascularization is often required.

METHODS

This is a retrospective observational study evaluating the incidence, trends, and predictors of revascularization after CABG surgery.

RESULTS

Of 2,476 patients followed in this post-CABG study, 1458 patients received dual antiplatelet therapy (DAPT) compared to 1005 patients received aspirin monotherapy (AMT). The overall incidence of revascularization was significantly higher in the DAPT group (14.54%, 212 out of 1458) compared to the AMT group (7.07%, 71 out of 1005), with an odds ratio (OR) of 2.24 (95% CI: 1.69-2.97, p < 0.001). 770 patients who received DAPT for six months or more after surgery were compared in sub-analysis and were noted to have significantly higher incidence of revascularization compared to AMT (22.08% vs. 6.96%; OR = 3.157, 95% CI: 2.734-4.940; p < 0.001). The binary regression model revealed that younger patients ( hazard ratio (HR) = 0.964, 95% CI: 0.95-0.97; p < 0.001), diabetics (HR = 1.50, 95% CI: 1.12-2.00, p = 0.007), patients who had fewer internal mammary artery grafts (HR = 0.54, 95% CI: 0.36-0.81, p = 0.003), and patients receiving DAPT of any duration after CABG (HR = 3.47, 95% CI: 2.55-4.72, p < 0.001) were more likely to receive revascularization after CABG. The model, comprising these four predictors, was able to explain 12.8% of the variance in post-CABG revascularization (Nagelkerke R² = 0.128; p < 0.001). The survival rates were 96.5% for the DAPT group and 92.0% for AMT (odds ratio (OR) = 0.421, 95% confidence interval (95% CI): 0.269-0.658; p < 0.001).

CONCLUSION

Diabetes mellitus, younger age, fewer Internal mammary artery grafts, and the use of DAPT after CABG were strong predictors of the need for secondary revascularization.

Impact of Warfarin and Dual Antiplatelet Therapy on Graft Failure After Coronary Endarterectomy: A Retrospective Cohort Study

PURPOSE

Coronary endarterectomy combined with coronary artery bypass grafting (CE-CABG) effectively achieves coronary revascularization in patients with diffuse atherosclerotic coronary artery disease (CAD). However, the loss of the subendothelial tissue at the CE-CABG coronary artery accelerates local thrombosis, leading to CE-CABG graft failure. Dual antiplatelet therapy (DAT) and warfarin plus aspirin (WPA) are the two most common anticoagulation strategies post CE-CABG. This retrospective study compares the clinical outcomes and graft failure rates associated with these two approaches.

METHODS

This study is a retrospective cohort study. Between July 2016 and April 2024, 102 patients with diffuse CAD underwent CE-CABG. Six patients were excluded. In total, 96 patients (mean age 59.8 ± 7.7 years) enrolled in the study (43 in DAT group and 53 in WPA group). The DAT group received aspirin (100 mg, qd) and clopidogrel (75 mg, qd) for 1 year postoperatively, transitioning to aspirin (100 mg, qd) after 1 year. The WPA group received warfarin (international normalized ratio, INR remained at 1.8-2.5) and aspirin (100 mg, qd) for 3 months postoperatively, followed by DAT after 3 months, changed to aspirin monotherapy after 1 year. The primary endpoint was graft failure of the CE-CABG graft.

RESULTS

Four patients died during the perioperative period (1 in DAT group, 3 in WPA group), resulting in an overall perioperative mortality rate of 4.2%. Five patients were lost for follow-up. Mean follow-up time was 38 months. Three patients died during the follow-up period (1 in DAT group, 2 in WPA group). The CE-CABG graft patency of the WPA group was significantly higher compared to the DAT group (88.1% vs. 50.0%, P < 0.001). Kaplan-Meier analysis showed that the median graft failure time was significantly longer in the WPA group (77 months, 95% CI 69-85) compared to the DAT group (73 months, 95% CI 17-129, P = 0.017). A higher proportion of the DAT group was classified as NYHA III-IV compared to the WPA group (26.2% vs. 10.2%, P = 0.046). One patient of the WPA group had a gastrointestinal bleeding event, and the overall incidence of bleeding events was not statistically different between the two groups.

CONCLUSION

Using the WPA strategy after CE-CABG significantly reduces the rate of graft failure and improves cardiac function without increasing the risk of bleeding events.

Clinical efficacy of clopidogrel and ticagrelor in patients undergoing off-pump coronary artery bypass grafting: a retrospective cohort study

BACKGROUND

Ticagrelor is reportedly more effective than clopidogrel in preventing atherothrombotic events in patients with percutaneous coronary intervention. However, the optimal antiplatelet therapy strategy after off-pump coronary artery bypass grafting (OPCABG) is yet to be established.

MATERIALS AND METHODS

This study was performed using the prospectively-maintained database at our institution. Patients who underwent OPCABG were divided into the clopidogrel and the ticagrelor groups. Propensity score matching analysis was performed between the two groups. The clinical outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of vascular death, myocardial infarction, or stroke 1-year after surgery.

RESULTS

In total, 545 patients completed the entire follow-up assessment. After propensity score matching, 232 patients each were included in the clopidogrel and ticagrelor groups. The primary outcome occurred in 7.8 and 4.3% of patients in the clopidogrel and ticagrelor groups, respectively ( P =0.113). CYP2C19 variants (*2, *3, and *17) did not impact the clinical outcomes, regardless of the use of clopidogrel or ticagrelor. The rates of MACE were significantly lower in patients carrying the ABCB1 C3435T CT/TT genotypes in the ticagrelor group than in those carrying the ABCB1 C3435T CC genotype in the clopidogrel group (1.4 vs. 9.1%, adjusted P =0.030), as well as those carrying the ABCB1 C3435T CC genotype in the ticagrelor group (1.4 vs. 8.9%, adjusted P =0.036). The ABCB1 C3435T CC genotype was significantly associated with the incidence of 1-year MACE (HR=1.558, 95% CI: 1.109-2.188, P =0.011). Patients who experienced severe perioperative bleeding exhibited a significantly higher incidence of MACE than those who did not experience severe perioperative bleeding (14.0 vs. 4.9%, adjusted P =0.007).

CONCLUSION

There was no significant difference in the 1-year MACE between patients receiving clopidogrel and those receiving ticagrelor after OPCABG. Notably, The ABCB1 C3435T CC genotype was related to a higher risk of MACE.

Coronary endarterectomy combined with coronary artery bypass grafting might decrease graft patency: A cohort study

BACKGROUND

Little is known about the graft patency after coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG). This study aimed to investigate the graft patency after CABG + CE.

METHODS

Eligible patients hospitalized at our center during September 2008 and July 2022 with complete follow-up coronary angiographic data available were retrospectively enrolled. The primary end point was the follow-up graft patency of CE targets. Logistic regression was performed to explore the potential predictors of the CE-targeted graft failure.

RESULTS

A total of 160 patients (age: 59.4 ± 9.3 years, male: 75.6%) were enrolled, and 560 grafts were anastomosed. CE was performed on 166 sites, including LAD (36.1%), right coronary artery (RCA, 48.2%), left circumflex artery (9.6%), and diagonal branches (6.0%). Postoperative myocardial infarction was observed in 7 (4.4%) of the patients. During a median follow-up of 12.1 months, the CE-targeted graft patency was 69.9%. The CE-targeted graft patency rate was much higher among the LAD-CE patients than the non-LAD-CE patients (80.0% vs. 64.2%, P = 0.032) but lower than non-endarterectomized LAD (80.0% vs. 92.9%, P = 0.013). No difference was observed regarding the graft patency between off-pump and on-pump surgery (P = 0.585). In the logistic regression, RCA-CE was associated with an increased risk of graft failure even after multiple adjustments (odds ratio: 2.35, 95% confidence interval: 1.05-5.28, P = 0.028).

CONCLUSIONS

CABG + CE might be associated with decreased graft patency, especially in those who received RCA-CE, irrespective of surgical technique or antiplatelet/anticoagulation regimen. A multi-center prospective, possibly randomized study with a larger sample size is warranted.

Short and long-term outcomes after off-pump coronary endarterectomy stratified by different target vessels

BACKGROUND

The efficacy of off-pump coronary endarterectomy (CE) has been proven in patients with diffuse coronary artery disease (DCAD). However, the clinical benefits of of-pump CE stratified by different target vessels remain controversial. This retrospective study assessed the effect of the territory and number of CE on short- and long-term outcomes of DCAD.

METHODS

From January 2012 to December 2014, 246 patients undergoing off-pump coronary artery bypass grafting (OPCABG) + CE were included. The patients were grouped by the territory and number of CE. The primary endpoints were postoperative acute myocardial infarction (PMI) and long-term major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Sixty-five patients (26.42%) were in the left anterior descending branch (LAD) group (CE on LAD), 134(54.47%) in the right coronary artery (RCA) group (CE on RCA), and 47(19.10%) in the multi-vessels group. PMI in the LAD group, RCA group, and multi-vessels group were 3.08%, 6.72%, and 14.89%, respectively (P = 0.08). Multi-vessels CE (OR = 9.042, 95%CI 2.198-37.193, P = 0.002), CE-plaque length ≥ 3 cm (OR = 6.247, 95%CI 2.162-18.052, P < 0.001), and type 2 diabetes mellitus (2DM) (OR = 4.072, 95%CI 1.598-10.374, P = 0.003) were independent risk factors of PMI. The long-term (mean 76 months) MACCE in the LAD group, RCA group, and multi-vessels group were 13.85%, 17.91%, and 10.64%, respectively (P = 0.552). Cox analysis indicated that PMI (HR = 7.113, 95%CI 3.129-16.171, P < 0.001) and Age ≥ 65 years (HR = 2.488, 95%CI 1.214-5.099, P = 0.013) increased the risk of long-term MACCE.

CONCLUSIONS

Multi-vessel CE and CE-plaque length ≥ 3 cm significantly increased risk of PMI after OPCABG + CE, but the territory and number of CE did not affect long-term MACCE.