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May - 2018

   

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Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting

Qiang Zhao, Yunpeng Zhu, Zhiyun Xu, et al. JAMA, 2018, 2018;319(16):1677-1686

Comment

Is aspirin alone, ticagrelor alone, or aspirin + ticagrelor better for saphenous vein graft graph patency after CABGs?

This prospective RCT enrolled 500 patients undergoing elective CABG, and randomised them 1:1:1 to these groups, receiving medication within 24 hours of surgery. High-risk patents, including high-risk of bleeding, were excluded. They report;

  • Patients and physicians were unblinded
  • Primary outcome was 1-yr SVG patency, assessed by multislice computed tomographic angiography or coronary angiography and adjudicated independently by a committee blinded to allocation. Rates were;
    • 88.7% ticagrelor + aspirin
    • 82.8% ticagrelor alone
    • 76.5% aspirin alone. 
    • Difference between ticagrelor + aspirin vs aspirin alone was statistically significant (12.2% [95% CI, 5.2% to 19.2%]; P < .001)
    • Difference between ticagrelor alone vs aspirin alone was not statistically significant (6.3% [95% CI, –1.1% to 13.7%]; P = .10). 
  • Five major bleeding episodes during (3 ticagrelor + aspirin; 2  ticagrelor alone)

This suggests the use of ticagrelor over aspirin is associated with better 1-yr graft patency after CABG in elective, low-risk patients. Doe sit lead to better functional outcomes? Is there a bleeding risk that would emerge, particularly in early postoperative period.  

 

Abstract

IMPORTANCE 

The effect of ticagrelor with or without aspirin on saphenous vein graft patency in patients undergoing coronary artery bypass grafting (CABG) is unknown.

OBJECTIVE 

To compare the effect of ticagrelor+aspirin or ticagrelor alone vs aspirin alone on saphenous vein graft patency 1 year after CABG.

DESIGN,SETTING,AND PARTICIPANTS Randomized, multicenter, open-label,clinical trial among 6 tertiary hospitals in China. Eligible patients were aged 18 to 80 years with indications for elective CABG. Patients requiring urgent revascularization, concomitant cardiac surgery, dual antiplatelet or vitamin K antagonist therapy post-CABG, and who were at risk of serious bleeding were excluded. From July 2014 until November 2015, 1256 patients were identified and 500 were enrolled. Follow-up was completed in January 2017.

INTERVENTIONS Patients were randomized(1:1:1) to start ticagrelor (90mg twice

daily) + aspirin (100 mg once daily) (n = 168), ticagrelor (90 mg twice daily) (n = 166), or aspirin (100 mg once daily) (n = 166) within 24 hours post-CABG. Neither patients nor treating physicians were blinded to allocation.

MAIN OUTCOMES AND MEASURES Primary outcome was saphenous vein graft patency 1-year after CABG (FitzGibbon grade A) adjudicated independently by a committee blinded to allocation. Saphenous vein graft patency was assessed by multislice computed tomographic angiography or coronary angiography.

RESULTS Among 500 randomized patients (mean age, 63.6 years; women, 91[18.2%]),461 (92.2%) completed the trial. Saphenous vein graft patency rates 1 year post-CABG were 88.7% (432 of 487 vein grafts) with ticagrelor + aspirin; 82.8% (404 of 488 vein grafts) with ticagrelor alone; and 76.5% (371 of 485 vein grafts) with aspirin alone. The difference between ticagrelor + aspirin vs aspirin alone was statistically significant (12.2% [95% CI, 5.2% to 19.2%]; P < .001), whereas the difference between ticagrelor alone vs aspirin alone was not statistically significant (6.3% [95% CI, –1.1% to 13.7%]; P = .10). Five major bleeding episodes occurred during 1 year of follow-up (3 with ticagrelor + aspirin; 2 with ticagrelor alone).

CONCLUSIONS AND RELEVANCE Among patients undergoing elective CABG with saphenous vein grafting, ticagrelor + aspirin significantly increased graft patency after 1 year vs aspirin alone; there was no significant difference between ticagrelor alone and aspirin alone. Further research with more patients is needed to assess comparative bleeding risks.

May


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