DAPT with aspirin prevents saphenous vein graft failure in CABG, finds BMJ study

Canada: Aspirin is the preferred antiplatelet drug for the prevention of saphenous vein graft failure in patients undergoing coronary artery bypass graft. Now, a meta-analysis published in the BMJ journal has shown the dual antiplatelet therapy (DAPT) with ticagrelor or clopidogrel to be superior to aspirin for the said purpose.

Patients with multivessel coronary artery disease are treated with coronary artery bypass grafting (CABG). But patients undergoing this procedure are at risk of subsequent major adverse cardiovascular events (MACE), causes mainly by the associated progression of saphenous vein graft failure, vascular damage or native coronary artery disease.

According to the authors, saphenous vein graft has high early failure rates, despite this, it remains the most commonly used graft in contemporary coronary artery bypass graft trials.

Karla Solo, clinical epidemiologist, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada, and colleagues assessed the effects of different oral antithrombotic drugs that prevent saphenous vein graft failure in patients undergoing CABG.

The analysis included 20 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. Some 4800 adults who received saphenous grafts were included; follow-up ranged from 1 month to 8 years.

The primary efficacy endpoint was saphenous vein graft failure and the primary safety endpoint was major bleeding. Secondary endpoints were myocardial infarction and death.

• Compared with aspirin monotherapy, DAPT with aspirin plus ticagrelor was associated with reduced risk for venous graft failure (odds ratio, 0.5), as was aspirin plus clopidogrel (OR, 0.6).


• The researchers calculated that 10 patients would need to receive aspirin plus ticagrelor or 19 would need to receive aspirin plus clopidogrel to prevent one graft failure.


• The risk for major bleeding did not differ significantly across active drug interventions.

"Our results suggest an important absolute benefit of ticagrelor or clopidogrel addition to aspirin for the prevention of saphenous vein graft failure after CABG. Dual antiplatelet therapy should be administered to patients undergoing CABG only after balancing the safety and efficacy profile of the drug intervention against important patient outcomes," write the authors.

"Future guideline updates are needed to optimise antithrombotic management of patients undergoing coronary artery bypass graft surgery. Meanwhile, dual antiplatelet therapy with aspirin plus ticagrelor or aspirin plus clopidogrel could be considered for most patients after surgery," they concluded.