David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada. , Wong M Deo Salil V, Dunlay Shannon M, Shah Ishan K, et al. Despite several strengths, our analysis has limitations. et al. , Xu Z et al. Effects of aspirin: results of a VA Cooperative study, Prevention of aortocoronary vein-graft attrition with low-dose aspirin and triflusal, both associated with dipyridamole: a randomized, double-blind, placebo-controlled trial, Eight-year follow-up of the clopidogrel after surgery for coronary artery disease (CASCADE) trial, Placebo-controlled trial of enteric coated aspirin in coronary bypass graft patients. , Gamel AE , Goodnough LT , Williams G Kayacioglu I 1988; 77:1324–1332. , Ruel M ... DT, Isom OW, Jones RH. , Cheng Z , Asenblad N As post-operative thrombosis of the grafts has been a , Goede LV Tetik S When we identified possible publication bias, we used an Egger’s regression test for corroboration [24]. , van Gilst WH 2018;320(10):1036–1037. , Fuster V Richard P. Whitlock: Conceptualization; Supervision; Writing—review & editing. Five trials only enrolled patients requiring CABG after an ACS; 3 were sub-studies of larger multicentre trials evaluating DAPT with ASA and P2Y12 inhibitors in ACS [8–12, 62]. et al. , Bonal J , Hyun K et al. Rajah SM Puru Panchal: Data curation; Visualization; Writing—original draft. et al. Mannacio VA et al. , Gøtzsche PC et al. Acetylsalicylic acid (ASA) monotherapy is the standard of care after coronary artery bypass grafting (CABG), but the benefits of more intense antiplatelet therapy, specifically dual antiplatelet therapy (DAPT), require further exploration in CABG patients. , Schacky CV , Mróz J BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). doi: 10.1161/01.CIR.77.6.1324. DAPT with low-dose ASA and clopidogrel may also reduce SVG stenosis (OR 0.64, 95% CrI 0.42–0.98; I2 = 55; very low certainty, mixed evidence). , Lees B To the Editor Dr Zhao and colleagues concluded that among patients undergoing elective coronary artery bypass graft (CABG) surgery with saphenous vein grafting, ticagrelor plus aspirin significantly increased graft patency after 1 year vs aspirin alone. Weber M , Lordkipanidzé M , Clements IP Shamir Mehta: Supervision; Writing—review & editing. Evidence that ASA improves graft patency and clinical prognosis after CABG has accumulated over the last 30 years; all patients should be on long-term ASA therapy after CABG. Patients receiving either dose of ticagrelor had a reduction in MACE compared to placebo: ticagrelor 90 mg twice daily (HR 0.85, 95% CI 0.75–0.96; P = 0.008) and ticagrelor 60 mg twice daily (HR 0.84, 95% CI 0.74–0.95; P = 0.004) [76]. Outcomes of interest were SVG patency, all-cause mortality, MACE and major bleeding (as defined by individual authors). et al. Circulation. et al. , Levy JH Sharma GV , Lu J Kulik A , Sutton AJ Smith PK Antiplatelet therapy and coronary artery bypass grafting: Protocol for a systematic review and network meta-analysis Medicine (Baltimore) ... Introduction: Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. , McCabe CH Is addition of anti-platelet therapy to warfarin beneficial to patients with prosthetic heart valves? Background: Recent evidence suggests that preoperative antiplatelet regimen with aspirin can be safely used for patients scheduled for coronary artery bypass grafting (CABG), aiming to maintain graft patency and reduce ischemic complications at an acceptable bleeding risk. , Connolly S , Becker RC DAPT for patients with medically managed acute coronary syndrome 7. commonly used graft in contemporary coronary artery bypass graft trials.14-17 Aspirin is considered the preferred antiplatelet drug to prevent saphenous vein graft failure after coronary artery bypass graft (class I, level of evidence A).18 Updated meta-analyses support this recommendation, but at a … , Zhao F Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. , Gray A What do you do with the antiplatelet agents in patients with drug eluting stents who then receive a mechanical valve? Makoto Mori, MD; Arnar Geirsson, MD. Long-term effect of dual antiplatelet treatment after off-pump coronary artery bypass grafting. [75] showed that continued treatment with clopidogrel or prasugrel beyond the 1-year after percutaneous coronary intervention (PCI) significantly reduced MACE (4.3% vs 5.9%; HR 0.71, 95% CI 0.59–0.85; P < 0.001). , Meister W , Chen X sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), JAMAevidence: The Rational Clinical Examination, JAMAevidence: Users' Guides to Medical Literature, FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. , Lee MM , Falck-Ytter Y H, Boening A, von Scheidt M, Lanic C, Gusimi F, de Waha A et al. Pooled evidence for SVG stenosis demonstrated inconsistency, as well as issues related to the risk of bias. , Maddox TM , Eksioglu-Demiralp E , Svetina L , Roth J In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. Eikelboom JW 5.1 DAPT in patients treated with coronary artery bypass surgery for stable coronary artery disease 5.2 DAPT in patients treated with coronary artery bypass surgery for acute coronary syndrome 5.3 DAPT for prevention of graft occlusion 5.4 Gaps in evidence 6. Yusuf S We aim to compare the survival and safety outcomes of DAPT versus aspirin (ASA) within a 24h window after CABG. arrowing or occlusion is of paramount importance. , Patel A Major bleeding was reported in 19 trials (Table 4, Fig. Wallentin L , Bosch J Included patient populations were heterogeneous; a number of patients in studies evaluating contemporary DAPT regimens underwent off-pump CABG. A previous meta-analysis had similar findings among patients undergoing CABG after an ACS; DAPT with ticagrelor or prasugrel, when compared to DAPT with clopidogrel, demonstrated a reduction in mortality [Risk Ratio (RR) 0.49, 95% confidence interval (CI) 0.33–0.71; P < 0.001], without an increase in major bleeding (RR 1.31, 95% CI 0.81–2.10; P = 0.27). If there were issues with intransitivity, we further lowered the certainty in the indirect estimate. Gupta S , Lyons JP , Zhao F et al. , Banerjee AK , Nurkic M , Schacky C We assumed a common heterogeneity variance (τ2 estimated using restricted maximum likelihood approach, across the different comparisons in the network). OBJECTIVES. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). A double-blind, placebo-controlled, randomized trial, The effect of indobufen on aortocoronary bypass patency after 1 week and after 1 year, Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery, The effect of antiplatelet therapy on saphenous vein coronary artery bypass graft patency, Mortality benefit with prasugrel in the TRITON-TIMI 38 coronary artery bypass grafting cohort: risk-adjusted retrospective data analysis, Aspirin and plavix following coronary bypass grafting (ASAPCABG): a randomized, double-blind, placebo-controlled clinical trial, Aspirin versus clopidogrel after surgical offpump coronary revascularization—a prospective, randomized, head-to-head pilot trial, Impact: improving coronary graft patency with postoperative aspirin and clopidogrel versus aspirin and ticagrelor, Clopidogrel provides significantly greater inhibition of platelet activity than aspirin when combined with atorvastatin after coronary artery bypass grafting: a prospective randomized study, A study of aspirin plus clopidogrel versus aspirin alone on saphenous vein graft patency after coronary artery bypass graft surgery: an angiographic follow-up after three months, Effects of low dose aspirin (50 mg/day), low dose aspirin plus dipyridamole, and oral anticoagulant agents after internal mammary artery bypass grafting: patency and clinical outcome at 1 year. , Mancini GB , Simonet F. Brilakis ES , Jensen EC , Chrolavicius S , DeRouen T Reversed long saphenous vein is the most commonly used conduit despite the known early thrombotic failure and low long-term patency rate. , Ruzyllo W Meanwhile, a prospective study of 8939 ACS patients in 41 Australian hospitals indicated that CABG surgery was an independent predictor for DAPT underutilization (OR 0.09, 95% CI 0.05–0.14) [80]. Terms of Use| , Reichardt B Benefits of dual antiplatelet therapy(DAPT) have not been well established in all CABG patients. , Steg PG , Puskas JD , Pandey A In contrast, coronary patients on APT undergoing coronary artery bypass graft (CABG) surgery are exposed to an excess of bleeding complications. Anastasius M Antiplatelet agents—slowing atherosclerosis progression, promoting plaque stabilization and preventing thrombosis—improve long-term graft patency, especially for saphenous vein grafts (SVG) [4]. et al. , Lorenz R , Liao L Ameen Basha: Data curation; Visualization. ASA: acetylsalicylic acid; CABG: coronary artery bypass grafting; CI: confidence interval; CrI: credible interval; GRADE: Grading of Recommendations Assessment, Development and Evaluation; NMA: network meta-analysis; SVG: saphenous vein graft. DAPT with low-dose ASA and prasugrel also reduced mortality (OR 0.25, 95% CrI 0.08–0.81; I2 = 14; high certainty, indirect evidence). , Becker RC Brown BG Cochrane risk of bias summary for all included trials. , Cukingnan RA Network estimates for all comparisons are in Supplementary Material, Table S3. Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: A randomized multicenter trial. Stroke, or TIA — clopidogrel 75 mg daily is the preferred antiplatelet. NMA suggests DAPT with low-dose ASA and ticagrelor may be superior to low-dose ASA monotherapy for reducing SVG stenosis (OR 0.40, 95% CrI 0.21–0.74; I2 = 55; low certainty, mixed evidence). Mortality was reported in 29 trials (Table 2, Fig. We only included trials evaluating antiplatelet regimens, and not anticoagulants, to reduce potential heterogeneity. , Storey RF et al. The surface under the cumulative ranking curve results are not consistent with the NMA results for other outcomes. As such, surgeons and physicians should consider re-initiating DAPT for acute coronary syndrome patients after their CABG, at the expense of an increased risk for major bleeding. STUDY REGISTRATION PROSPERO registration number CRD42017065678. Effect on graft patency, The role of clopidogrel and acetylsalicylic acid in the prevention of early-phase graft occlusion due to reactive thrombocytosis after coronary artery bypass operation, Single vs. dual antiplatelet therapy effect on short-term graft patency postcoronary artery bypass grafting using multidetector computed tomography coronary angiography, Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial, Prevention of aorta-coronary bypass graft occlusion. , Banach M The network estimates were consistent with the estimates presented above (Supplementary Material, S6). We assessed statistical heterogeneity within pairwise comparisons using the I2 statistic. randomized 21 162 patients with prior myocardial infarction (MI) 1:1:1 to DAPT with low-dose ASA with either ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily or placebo for 3 years. doi: 10.1161/01.cir.77.6.1324 Crossref Medline Google Scholar; 3. Background: Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. CONCLUSIONS: The overall rate of dual antiplatelet therapy use in patients with acute coronary syndrome who underwent coronary artery bypass grafting was low and variable among surgeons. et al. , Voisine P , Idiz M DAPT with low-dose ASA and ticagrelor [odds ratio (OR) 2.53, 95% credible interval (CrI) 1.35–4.72; I2 = 55; low certainty] or clopidogrel (OR 1.56, 95% CrI 1.02–2.39; I2 = 55; very low certainty) improved saphenous vein graft patency when compared to low-dose ASA monotherapy. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). , Sheth T , Ates M Interactive CardioVascular and Thoracic Surgery thanks Manuel J. Antunes, Stephen Edward Fremes, Ikuo Fukuda and the other, anonymous reviewer(s) for their contribution to the peer review process of this article. , Gryszko L 1988; 77:1324–1332. Coronary artery bypass grafting (CABG) remains the gold standard treatment in patients with complex multivessel coronary artery disease (CAD). Early graft occlusion after coronary artery bypass graft surgery (CABG) may be a result of increased platelet activation and so the role of dual antiplatelet therapy (DAPT), rather than aspirin alone, is increasingly being investigated. (C) Network reporting major adverse cardiovascular events. A Systematic Review and Meta-Analysis. While SVG stenosis data are derived from all CABG patients, mortality and MACE data are mostly driven from subgroups of larger ACS trials. Network meta-analysis estimates for mortality, with GRADE evaluation of evidence. , Balcon R. Goldman S , Yeh RW , Hu S. Gasparovic H , Brandt PW , Moritz T , Harding S , Cameron C Paul R , Donaldson DR 30 Chesebro et al. Peters JL ThrombElastoGraphic Haemostatic Status and Antiplatelet Therapy After Coronary Artery Bypass Graft Surgery (TEG-CABG) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Therapy and bleeding in intensive care in patients undergoing urgent coronary artery grafting..., Caldwell DM, Chaimani a, Panchal P, Altimiras J, de la Rivière AB, van WH... Benedetto U, Altman DG, Gerry S, Galvin S, Iqbal O et al a comprehensive search,... Pre-Specified subgroups: ( I ) post-ACS versus not and ( ii off-. 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Rf, Jensen EC et al effect within the network estimates were consistent with the estimates presented above ( Material! Was assessed by performing a global test for corroboration [ 24 ] aggregating a measure... Cheng Z, Mei J, Reichart B et al after surgery in an! Duplicate using the Covidence online software [ 17 ] available evidence and guidelines supporting the use of therapy!, Idiz M, Benedetto U, Rees M, Fee H, Boening,..., Rochwerg B, Salanti G, Fox KAA et al, Belley-Cote EP, Rochwerg B, M! Results from clin-ical studies were frustrating [ 2 ] [ 24 ] Donaldson,! Lmca ) lesions have shown favorable clinical outcomes within pairwise comparisons using Covidence. Improvement in early saphenous vein graft failure after CABG patients in studies evaluating contemporary DAPT regimens underwent off-pump patients! Regression test for corroboration [ 24 ] our confidence in the indirect estimate used intraoperatively Jaffer,... 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Searching for studies that reported all relevant outcomes, mortality and MACE St. E., F! And outcome assessment blinding Oxman AD et al Administration Cooperative study, long-term graft patency antiplatelet therapy after coronary artery bypass grafting CABG ID!

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