Should dual antiplatelet therapy be used in patients following coronary artery bypass surgery? A meta-analysis of randomized controlled trials Vascular and thoracic surgery

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∈