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von Scheidt M, Bongiovanni D, Tebbe U, Nowak B, Stritzke J, Zhao Q, Zhu Y, Kastrati A, Cassese S, Schunkert H. Ticagrelor-based antiplatelet regimens in patients treated with coronary artery bypass grafting: a meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg 2020; 57:520-528. [PMID: 31566205 DOI: 10.1093/ejcts/ezz260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/08/2019] [Accepted: 08/26/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The optimal antiplatelet strategy in patients undergoing CABG remains unclear. This is the first meta-analysis investigating the clinical outcomes associated with ticagrelor-based antiplatelet regimens in patients receiving CABG. METHODS Relevant scientific databases were searched for studies investigating antiplatelet regimens after CABG from inception until April 1, 2019. Studies which randomly assigned CABG patients to either ticagrelor-based or control antiplatelet regimens were eligible. The primary outcome of this analysis was all-cause death. The main secondary outcome was MI. Other outcomes of interest were cardiac death, major adverse cardiac events, stroke and bleeding. This study is registered with PROSPERO, number CRD42019122192. RESULTS Five trials comprising 3996 patients (2002 assigned to ticagrelor-based and 1994 to control antiplatelet regimens) were eligible for quantitative synthesis. The median follow-up was 12 months. Control antiplatelet regimens consisted of either aspirin or clopidogrel or both. As compared to control, ticagrelor-based regimens reduced the risk of all-cause death [0.61 (0.43-0.87); P = 0.007], cardiac death [0.58 (0.39-0.86); P = 0.007] and major adverse cardiac events [0.79 (0.63-0.98); P = 0.03], without difference in the risk of MI [0.76 (0.50-1.18); P = 0.22], stroke [0.99 (0.56-1.78); P = 0.98] or bleeding [1.04 (0.95-1.14); P = 0.41]. There was a treatment effect modification for the primary outcome associated with trials enrolling predominantly patients with acute coronary syndrome (P for interaction = 0.038). CONCLUSIONS In patients receiving CABG, ticagrelor-based regimens reduce mortality and major adverse cardiac events without excess bleeding risk as compared with aspirin monotherapy or the combination of aspirin and clopidogrel. The benefit of ticagrelor-based regimens is more relevant in those studies enrolling predominantly patients with acute coronary syndrome. These findings require further confirmation in randomized trials focused on this subset of patients and powered for clinical outcomes.
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Affiliation(s)
- Moritz von Scheidt
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Dario Bongiovanni
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.,Medical Department I, Cardiology, Klinikum rechts der Isar, Technical University, Munich, Germany
| | - Ulrich Tebbe
- Department of Cardiology, Angiology, and Intensive Care Medicine, District Hospital Lippe-Detmold, Detmold, Germany
| | - Bernd Nowak
- CCB, Cardiovascular Center Bethanien, Frankfurt, Germany
| | - Jan Stritzke
- Lanserhof Sylt, Marienstein Privatklinik, List, Germany
| | - Qiang Zhao
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunpeng Zhu
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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Franzone A, McFadden E, Leonardi S, Piccolo R, Vranckx P, Serruys PW, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, Diletti R, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Steg PG, Heg D, Jüni P, Windecker S, Valgimigli M. Ticagrelor Alone Versus Dual Antiplatelet Therapy From 1 Month After Drug-Eluting Coronary Stenting. J Am Coll Cardiol 2019; 74:2223-2234. [DOI: 10.1016/j.jacc.2019.08.1038] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/08/2019] [Accepted: 08/10/2019] [Indexed: 11/17/2022]
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Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College, and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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Solo K, Lavi S, Kabali C, Levine GN, Kulik A, John-Baptiste AA, Fremes SE, Martin J, Eikelboom JW, Ruel M, Huitema AA, Choudhury T, Bhatt DL, Tzemos N, Mamas MA, Bagur R. Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis. BMJ 2019; 367:l5476. [PMID: 31601578 PMCID: PMC6785742 DOI: 10.1136/bmj.l5476] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the effects of different oral antithrombotic drugs that prevent saphenous vein graft failure in patients undergoing coronary artery bypass graft surgery. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, Embase, Web of Science, CINAHL, and the Cochrane Library from inception to 25 January 2019. ELIGIBILITY CRITERIA: for selecting studies Randomised controlled trials of participants (aged ≥18) who received oral antithrombotic drugs (antiplatelets or anticoagulants) to prevent saphenous vein graft failure after coronary artery bypass graft surgery. MAIN OUTCOME MEASURES The primary efficacy endpoint was saphenous vein graft failure and the primary safety endpoint was major bleeding. Secondary endpoints were myocardial infarction and death. RESULTS This review identified 3266 citations, and 21 articles that related to 20 randomised controlled trials were included in the network meta-analysis. These 20 trials comprised 4803 participants and investigated nine different interventions (eight active and one placebo). Moderate certainty evidence supports the use of dual antiplatelet therapy with either aspirin plus ticagrelor (odds ratio 0.50, 95% confidence interval 0.31 to 0.79, number needed to treat 10) or aspirin plus clopidogrel (0.60, 0.42 to 0.86, 19) to reduce saphenous vein graft failure when compared with aspirin monotherapy. The study found no strong evidence of differences in major bleeding, myocardial infarction, and death among different antithrombotic therapies. The possibility of intransitivity could not be ruled out; however, between-trial heterogeneity and incoherence were low in all included analyses. Sensitivity analysis using per graft data did not change the effect estimates. CONCLUSIONS The results of this network meta-analysis suggest an important absolute benefit of adding ticagrelor or clopidogrel to aspirin to prevent saphenous vein graft failure after coronary artery bypass graft surgery. Dual antiplatelet therapy after surgery should be tailored to the patient by balancing the safety and efficacy profile of the drug intervention against important patient outcomes. STUDY REGISTRATION PROSPERO registration number CRD42017065678.
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Affiliation(s)
- Karla Solo
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Cochrane Canada Center, MacGRADE Center and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Shahar Lavi
- London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Conrad Kabali
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Glenn N Levine
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Kulik
- Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, and Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ava A John-Baptiste
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Anesthesia & Perioperative Medicine and Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, ON, Canada
- Interfaculty Program in Public Health, Western University, London, ON, Canada
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Janet Martin
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Anesthesia & Perioperative Medicine and Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ashlay A Huitema
- London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Tawfiq Choudhury
- London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikolaos Tzemos
- London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke on Trent, UK
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke on Trent, UK
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Lüscher TF. The spectrum of chronic coronary syndromes: genetics, imaging, and management after PCI and CABG. Eur Heart J 2019; 40:2381-2384. [PMID: 33215649 DOI: 10.1093/eurheartj/ehz518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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