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Benedetto U, Altman DG, Gerry S, Gray A, Lees B, Flather M, Taggart DP. Impact of dual antiplatelet therapy after coronary artery bypass surgery on 1-year outcomes in the Arterial Revascularization Trial. Eur J Cardiothorac Surg 2018; 52:456-461. [PMID: 28387790 DOI: 10.1093/ejcts/ezx075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/12/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES There is still little evidence to boldport routine dual antiplatelet therapy (DAPT) with P2Y12 antagonists following coronary artery bypass grafting (CABG). The Arterial Revascularization Trial (ART) was designed to compare 10-year survival after bilateral versus single internal thoracic artery grafting. We aimed to get insights into the effect of DAPT (with clopidogrel) following CABG on 1-year outcomes by performing a post hoc ART analysis. METHODS Among patients enrolled in the ART (n = 3102), 609 (21%) and 2308 (79%) were discharged on DAPT or aspirin alone, respectively. The primary end-point was the incidence of major adverse cerebrovascular and cardiac events (MACCE) at 1 year including cardiac death, myocardial infarction, cerebrovascular accident and reintervention; safety end-point was bleeding requiring hospitalization. Propensity score (PS) matching was used to create comparable groups. RESULTS Among 609 PS-matched pairs, MACCE occurred in 34 (5.6%) and 34 (5.6%) in the DAPT and aspirin alone groups, respectively, with no significant difference between the 2 groups [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.59-1.59; P = 0.90]. Only 188 (31%) subjects completed 1 year of DAPT, and in this subgroup, MACCE rate was 5.8% (HR 1.11, 95% CI 0.53-2.30; P = 0.78). In the overall sample, bleeding rate was higher in DAPT group (2.3% vs 1.1%; P = 0.02), although this difference was no longer significant after matching (2.3% vs 1.8%; P = 0.54). CONCLUSIONS Based on these findings, when compared with aspirin alone, DAPT with clopidogrel prescribed at discharge was not associated with a significant reduction of adverse cardiac and cerebrovascular events at 1 year following CABG.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alastair Gray
- Department of Public Health, Health Economics Research Centre, University of Oxford, Headington, Oxford, UK
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Marcus Flather
- Research and Development Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Zhao Y, Peng H, Li X, Qin Y, Cao F, Peng D, Liu J. Dual antiplatelet therapy after coronary artery bypass surgery: is there an increase in bleeding risk? A meta-analysis. Interact Cardiovasc Thorac Surg 2017; 26:573-582. [PMID: 29237042 DOI: 10.1093/icvts/ivx374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/27/2017] [Indexed: 01/11/2023] Open
Affiliation(s)
- Yejing Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongyu Peng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaonan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujun Qin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fangying Cao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ding Peng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinghua Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Verma S, Goodman SG, Mehta SR, Latter DA, Ruel M, Gupta M, Yanagawa B, Al-Omran M, Gupta N, Teoh H, Friedrich JO. Should dual antiplatelet therapy be used in patients following coronary artery bypass surgery? A meta-analysis of randomized controlled trials. BMC Surg 2015; 15:112. [PMID: 26467661 PMCID: PMC4605093 DOI: 10.1186/s12893-015-0096-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 10/01/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND We assessed the effectiveness of dual antiplatelet therapy (DAPT) post elective or urgent (i.e., post acute coronary syndrome [ACS]) coronary artery bypass graft surgery (CABG). METHODS We systematically searched MEDLINE, EMBASE, and the Cochrane Registry from inception to August 2015. Randomized controlled trials (RCTs) in adults undergoing CABG comparing either dual vs. single antiplatelet therapy or higher- vs. lower-intensity DAPT were identified. RESULTS Nine RCTs (n = 4,887) with up to 1y follow-up were included. Five RCTs enrolled patients post-elective CABG (n = 986). Two multi-centre RCTs enrolled ACS patients who subsequently underwent CABG (n = 2,155). These 7 RCTs compared clopidogrel plus aspirin to aspirin alone. Two other multi-centre RCTs reported on ACS patients who subsequently underwent CABG comparing higher intensity DAPT with either ticagrelor (n = 1,261) or prasugrel (n = 485) plus aspirin to clopidogrel plus aspirin. Post-operative anti-platelet therapy was started when chest tube bleeding was no longer significant, typically within 24-48 h. There were no differences in all-cause mortality in clopidogrel plus aspirin vs. aspirin RCTs; conversely, all-cause mortality was significantly lower in ticagrelor and prasugrel vs. clopidogrel RCTs (risk ratio[RR] 0.49, 95% confidence interval[CI] 0.33-0.71, p = 0.0002; 2 RCTs, n = 1695; I(2) = 0%; interaction p < 0.01 compared to clopidogrel plus aspirin vs aspirin RCTs). There were no differences in myocardial infarctions, strokes, or composite outcomes. Overall, major bleeding was not significantly increased (RR 1.31, 95% CI 0.81-2.10, p = 0.27; 7 RCTs, n = 4500). There was heterogeneity (I(2) = 42%) due almost entirely to higher bleeding reported for the prasugrel RCT which included mainly CABG-related major bleeding (RR 3.15, 95% CI 1.45-6.87, p = 0.004; 1 RCT, n = 437). CONCLUSIONS Most RCT data for DAPT post CABG is derived from subgroups of ACS patients in DAPT RCTs requiring CABG who resume DAPT post-operatively. Limited RCT data with heterogeneous trial designs suggest that higher intensity (prasugrel or ticagrelor) but not lower intensity (clopidogrel) DAPT is associated with an approximate 50% lower mortality in ACS patients who underwent CABG based on post-randomization subsets from single RCTs. Large prospective RCTs evaluating the use of DAPT post-CABG are warranted to provide more definitive guidance for clinicians.
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Affiliation(s)
- Subodh Verma
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
- />King Saud University, Riyadh, 12372 Saudi Arabia
| | - Shaun G. Goodman
- />Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Shamir R. Mehta
- />Department of Medicine, McMaster University, Hamilton, ON L8L 2X2 Canada
- />Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8L 2X2 Canada
| | - David A. Latter
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Marc Ruel
- />University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7 Canada
| | - Milan Gupta
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
- />Department of Medicine, McMaster University, Hamilton, ON L8L 2X2 Canada
- />Canadian Cardiovascular Research Network, Brampton, ON L6Z 4N5 Canada
| | - Bobby Yanagawa
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Mohammed Al-Omran
- />Division of Vascular Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
- />King Saud University, Riyadh, 12372 Saudi Arabia
| | | | - Hwee Teoh
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Division of Endocrinology & Metabolism, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
| | - Jan O. Friedrich
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Critical Care, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
- />Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON M5S 2J7 Canada
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Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, Lopez-Jimenez F, McNallan SM, Patel M, Roger VL, Sellke FW, Sica DA, Zimmerman L. Secondary Prevention After Coronary Artery Bypass Graft Surgery. Circulation 2015; 131:927-64. [DOI: 10.1161/cir.0000000000000182] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Brainard BM, Goggs R, Mendez-Angulo JL, Mudge MC, Ralph AG, Wiinberg B. Systematic evaluation of evidence on veterinary viscoelastic testing Part 5: Nonstandard assays. J Vet Emerg Crit Care (San Antonio) 2014; 24:57-62. [DOI: 10.1111/vec.12146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Benjamin M. Brainard
- Department of Small Animal Medicine and Surgery; College of Veterinary Medicine; University of Georgia; Athens GA 30602
| | - Robert Goggs
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY 14853
| | | | - Margaret C. Mudge
- College of Veterinary Medicine; Ohio State University; Columbus OH 43210
| | - Alan G. Ralph
- College of Veterinary Medicine; Department of Small Animal Clinical Sciences; Michigan State University; East Lansing MI 48823
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Leon ND, Jackevicius CA. Use of Aspirin and Clopidogrel After Coronary Artery Bypass Graft Surgery. Ann Pharmacother 2012; 46:678-87. [DOI: 10.1345/aph.1q692] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the evidence for the use of dual antiplatelet therapy (DAPT) with aspirin and Clopidogrel following coronary artery bypass graft (CABG) surgery. Data Sources: Literature was accessed through PubMed (1950-November 2011), EMBASE (1976-November 2011), and the Cochrane databases using the terms Clopidogrel and coronary artery bypass graft. Citations from available articles were used for additional references and ClinicalTrials.gov was accessed for abstracts of ongoing studies. Study Selection Ano Data Extraction: Peer-reviewed studies that evaluated DAPT use after CABQ surgery in adult humans were assessed for inclusion. Data Synthesis: Four randomized clinical trials evaluating surrogate end points and 9 studies (3 subgroup analyses, 6 observational) evaluating clinical outcomes were reviewed. Three clinical trials assessing surrogate end points failed to demonstrate an improvement in graft patency with DAPT use, while 1 clinical trial found an increase in graft patency. As for clinical outcomes, 1 subgroup analysis demonstrated that the benefit of DAPT post-CABG after a non-ST-elevation acute coronary syndrome diminished following surgery, while an observational study demonstrated a trend toward decreased mortality. In post-CABG patients who did not experience acute coronary syndrome, 2 subgroup analyses proved inconclusive and an observational study found DAPT use to be associated with reducing in-hospital mortality, while another observational study was not associated with reduced long-term mortality. Three observational studies in off-pump CABG patients showed that DAPT use was feasible. Conclusions: Evidence for DAPT use following CABG is limited to subgroup analyses, observational studies, and trials with surrogate end points. The majority of clinical trials have failed to demonstrate an improvement in graft patency with DAPT. Current evidence does not support the use of DAPT to improve graft patency, and more evidence from randomized controlled trials assessing clinical outcomes is necessary to make definitive recommendations.
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Affiliation(s)
- Noelle de Leon
- Resident and Instructor of Pharmacy Practice, College of Pharmacy, Western University of Health Sciences, Pomona, CA
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences; Clinical Pharmacy Specialist, Cardiology, Veterans Affairs Greater Los Angeles Healthcare System; Pharmacy Department, University Health Network-Toronto General Hospital, Toronto, ON, Canada; Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto
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Raja SG, Akhtar S. Hypercoagulable state after off-pump coronary artery bypass grafting: evidence, mechanisms and implications. Expert Rev Cardiovasc Ther 2011; 9:599-608. [PMID: 21615323 DOI: 10.1586/erc.11.51] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
During the past decade, there has been a dramatic resurgence in the adoption of off-pump technology in coronary artery bypass surgery. This has inspired remarkable advances in the techniques of localized tissue stabilization and a greater understanding of the physiology of beating-heart mobilization and exposure. An avalanche of reports in the literature has demonstrated the early safety and efficacy of the procedure. However, despite abundant evidence validating the safety and efficacy of off-pump coronary artery bypass surgery, considerable controversy still persists regarding the long-term outcomes of this approach to myocardial revascularization. One area of concern, and even greater uncertainty, surrounds the issue of the existence of a hypercoagulable state after off-pump coronary artery bypass surgery. This article evaluates the current best evidence available from randomized controlled trials to assess the impact of off-pump coronary artery bypass surgery on coagulation, fibrinolysis and platelet activation, discusses the issue of hypercoagulability with emphasis on the mechanisms responsible for this actual or potential hypercoagulability, and explores the implications of this issue for clinical practice.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Harefield, London, UB9 6JH, UK.
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Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the Preoperative Aspirin and Postoperative Antiplatelets in Coronary Artery Bypass Grafting study. Am Heart J 2010; 160:1178-84. [PMID: 21146675 DOI: 10.1016/j.ahj.2010.07.035] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Accepted: 07/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Routine use of postoperative aspirin after coronary artery bypass grafting (CABG) reduces graft failure and cardiovascular events. The efficacy and safety of adding clopidogrel to aspirin for the prevention of graft failure and cardiovascular events after CABG are unknown. We performed a pilot study measuring safety and efficacy outcomes of aspirin and clopidogrel therapy after CABG. METHODS We randomized 100 patients undergoing CABG to receive placebo or clopidogrel started after surgery and for 30 days. All patients received aspirin 81 mg daily. Graft patency was measured by cardiac computed tomography angiography at 30 days. RESULTS Clinical follow-up was complete for 99 patients, and 79 (80%) underwent computed tomography angiography. The proportion of patients with ≥1 occluded graft was not significantly different between placebo and clopidogrel groups (9/39 [23.1%] vs 7/40 [17.5%], relative risk 0.95, 95% CI 0.80-1.14, P=.54). Among radial artery grafts, the placebo group had a significantly higher number of occlusions or "string signs" compared with the clopidogrel group (7/16 [43.8%] vs 2/19 [10.5%], relative risk 0.24, 95% CI 0.06-1.00, P=.05). There was no difference between placebo and clopidogrel groups in the safety outcomes of total postoperative bleeding, transfusions, bleeding events, and reexploration and in the efficacy outcomes of nonfatal myocardial infarction, stroke, and death. CONCLUSIONS This pilot study confirms a high rate of graft occlusion after CABG surgery and suggests that the addition of clopidogrel to aspirin is feasible and safe and may be superior for prevention of graft failure in radial artery grafts.
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Patel JH, Stoner JA, Owora A, Mathew ST, Thadani U. Evidence for using clopidogrel alone or in addition to aspirin in post coronary artery bypass surgery patients. Am J Cardiol 2009; 103:1687-93. [PMID: 19539077 DOI: 10.1016/j.amjcard.2009.02.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 02/05/2009] [Accepted: 02/05/2009] [Indexed: 10/20/2022]
Abstract
Clopidogrel is recommended with aspirin for patients who undergo coronary artery bypass grafting (CABG) after non-ST elevation myocardial infarctions. Cardiothoracic surgeons widely use clopidogrel in addition to aspirin for post-CABG patients, including those with stable coronary artery disease. The aim of this study was to systematically review the published research to determine whether clopidogrel use after CABG is based on good trial data. Studies reporting safety and/or efficacy data for clopidogrel use with or without aspirin after on- or off-pump CABG were included. Fourteen studies met the inclusion criteria, of which 11 were reported trials and 3 are ongoing trials. Subgroup retrospective analyses of previously reported large trials of patients presenting with acute coronary syndromes (n = 1) or patients with stable coronary artery disease (n = 3) did not show a clear clinical benefit of clopidogrel when given in addition to aspirin after CABG. In contrast, there was a trend toward increased major and minor bleeding after the use of clopidogrel plus aspirin. Two small prospective trials providing data on surrogate end points and 5 small trials involving off-pump CABG patients were not of good quality to draw meaningful conclusions. In conclusion, summarized data based on subgroup analyses, surrogate end points, and observational cohort studies fail to demonstrate a clear beneficial effect of clopidogrel alone or in combination with aspirin on clinical outcomes after CABG.
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