Ticagrelor plus aspirin <i>versus</i> clopidogrel plus aspirin on graft patency after coronary artery bypass graft surgery: A randomized controlled trial_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

GAO Yang , WANG Wenjun , GAO Feng , SHI Lei ,  ZHUANG Xijing

Department of Cardiovascular Surgery, Dalian Municipal Central Hospital, Dalian, 116000, Liaoning, P.R.China;

Corresponding author：

ZHUANG Xijing, Email: dlmchcsd@126.com

Keywords：

Coronary artery bypass graft surgery; dual antiplatelet therapy; ticagrelor; clopidogrel

DOI：

10.7507/1007-4848.201811067

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Objective To compare the effect of aspirin+ticagrelor and aspirin+clopidogrel on graft patency one year after coronary artery bypass grafting (CABG).Methods A total of 67 patients who received CABG in our department from January 2014 to September 2017 were included in this study (52 males and 15 females). They were randomly divided into a group A (aspirin+clopidogrel) and a group B (aspirin+ticagrelor). There were 34 participants in the group A (28 males and 6 females) and 33 patients in the group B (24 males and 9 females). All patients were invited for clinical follow-up and 64-slice multislice computed tomography angiography (MSCTA) analysis in 1 year postoperatively. Cardiovascular events, bleeding events and other adverse events were followed up.Results Four patients were lost to follow-up. Two patients died. A total of 61 patients (48 males and 13 females) completed coronary CTA, and 31 in the group A (25 males and 6 females) and 30 in the group B (23 males and 7 females). The total number of bridged vessels was 156 (59 internal thoracic artery bridges and 97 great saphenous vein bridges), including 79 in the group A (31 internal thoracic artery bridges and 48 great saphenous vein bridges) and 77 in the group B (28 internal thoracic artery bridges and 49 great saphenous vein bridges). Graft patency rate 1 year post CABG was 82.3% (65/79) in the group A and 92.2% (71/77) in the group B (P>0.05). Artery graft patency rate 1 year post CABG was 96.8% (30/31) in the group A and 96.4% (27/28) in the group B (P>0.05). Saphenous vein graft patency rate 1 year post CABG was 72.9% (35/48) in the group A and 89.8% (44/49) in the group B (P<0.05). Multivariable analysis with binary logistic regression showed ticagrelor use reduced graft occlusion (OR=0.282, 95%CI 0.093 to 0.862, P<0.05). There was no significant difference in adverse events between the two groups.Conclusion Compared with clopidogrel plus aspirin, ticagrelor added to aspirin after CABG may enhance the saphenous graft patency without the excess risk of bleeding 1 year post CABG.

Citation： GAO Yang, WANG Wenjun, GAO Feng, SHI Lei, ZHUANG Xijing. Ticagrelor plus aspirin versus clopidogrel plus aspirin on graft patency after coronary artery bypass graft surgery: A randomized controlled trial. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(9): 874-878. doi: 10.7507/1007-4848.201811067 Copy

1.	Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation, 2015, 131(10): 927-964.
2.	Gao G, Zheng Z, Pi Y, et al. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial. J Am Coll Cardiol, 2010, 56(20): 1639-1643.
3.	Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA, 2018, 319(16): 1677-1686.
4.	Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Kardiol Pol, 2017, 75(12): 1217-1299.
5.	中国冠状动脉旁路移植术后二级预防专家共识组. 中国冠状动脉旁路移植术后二级预防专家共识(2016版). 中华胸心血管外科杂志, 2016, 32(10): 577-583.
6.	Fitzgibbon GM, Kafka HP, Leach AJ, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5, 065 grafts related to survival and reoperation in 1, 388 patients during 25 years. J Am Coll Cardiol, 1996, 28(3): 616-626.
7.	Hicks KA, Tcheng JE, Bozkurt B, et al. 2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials: a report of the American College of Cardiology/American Heart Association Task Force on clinical data standards (writing committee to develop cardiovascular endpoints data standards). J Am Coll Cardiol, 2015, 66(4): 403-469.
8.	Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation, 2011, 123(23): 2736-2747.
9.	Alexander JH, Smith PK. Coronary-artery bypass grafting. N Engl J Med, 2016, 374(20): 1954-1964.
10.	Locker C, Schaff HV, Dearani JA, et al. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease. Circulation, 2012, 126(9): 1023-1030.
11.	Dimitrova KR, Hoffman DM, Geller CM, et al. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg, 2012, 94(2): 475-481.
12.	Samano N, Geijer H, Liden M, et al. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: A randomized trial. J Thorac Cardiovasc Surg, 2015, 150(4): 880-888.
13.	杨溢, 朱云鹏, 李海清, 等. 大隐静脉: 冠状动脉旁路移植术的第二移植物. 中华胸心血管外科杂志, 2017, 33(4): 253-256.
14.	Halabi AR, Alexander JH, Shaw LK, et al. Relation of early saphenous vein graft failure to outcomes following coronary artery bypass surgery. Am J Cardiol, 2005, 96(9): 1254-1259.
15.	Gaudino M, Antoniades C, Benedetto U, et al. Mechanisms, consequences, and prevention of coronary graft failure. Circulation, 2017, 136(18): 1749-1764.
16.	Kulik A, Chan V, Ruel M. Antiplatelet therapy and coronary artery bypass graft surgery: perioperative safety and efficacy. Expert Opin Drug Saf, 2009, 8(2): 169-182.
17.	Deo SV, Dunlay SM, Shah IK, et al. Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis. J Card Surg, 2013, 28(2): 109-116.
18.	Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol, 2013, 112(10): 1576-1579.
19.	Mannacio VA, Di Tommaso L, Antignan A, et al. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypaSS occlusion After off-pump procedures) randomised study. Heart, 2012, 98(23): 1710-1715.
20.	Saw J, Wong GC, Mayo J, et al. Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery. Heart, 2016, 102(10): 763-769.
21.	Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med, 2015, 372(19): 1791-1800.
22.	Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med, 2009, 361(11): 1045-1057.
23.	Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol, 2011, 57(6): 672-684.

1. Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation, 2015, 131(10): 927-964.
2. Gao G, Zheng Z, Pi Y, et al. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial. J Am Coll Cardiol, 2010, 56(20): 1639-1643.
3. Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA, 2018, 319(16): 1677-1686.
4. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Kardiol Pol, 2017, 75(12): 1217-1299.
5. 中国冠状动脉旁路移植术后二级预防专家共识组. 中国冠状动脉旁路移植术后二级预防专家共识(2016版). 中华胸心血管外科杂志, 2016, 32(10): 577-583.
6. Fitzgibbon GM, Kafka HP, Leach AJ, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5, 065 grafts related to survival and reoperation in 1, 388 patients during 25 years. J Am Coll Cardiol, 1996, 28(3): 616-626.
7. Hicks KA, Tcheng JE, Bozkurt B, et al. 2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials: a report of the American College of Cardiology/American Heart Association Task Force on clinical data standards (writing committee to develop cardiovascular endpoints data standards). J Am Coll Cardiol, 2015, 66(4): 403-469.
8. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation, 2011, 123(23): 2736-2747.
9. Alexander JH, Smith PK. Coronary-artery bypass grafting. N Engl J Med, 2016, 374(20): 1954-1964.
10. Locker C, Schaff HV, Dearani JA, et al. Multiple arterial grafts improve late survival of patients undergoing coronary artery bypass graft surgery: analysis of 8622 patients with multivessel disease. Circulation, 2012, 126(9): 1023-1030.
11. Dimitrova KR, Hoffman DM, Geller CM, et al. Arterial grafts protect the native coronary vessels from atherosclerotic disease progression. Ann Thorac Surg, 2012, 94(2): 475-481.
12. Samano N, Geijer H, Liden M, et al. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: A randomized trial. J Thorac Cardiovasc Surg, 2015, 150(4): 880-888.
13. 杨溢, 朱云鹏, 李海清, 等. 大隐静脉: 冠状动脉旁路移植术的第二移植物. 中华胸心血管外科杂志, 2017, 33(4): 253-256.
14. Halabi AR, Alexander JH, Shaw LK, et al. Relation of early saphenous vein graft failure to outcomes following coronary artery bypass surgery. Am J Cardiol, 2005, 96(9): 1254-1259.
15. Gaudino M, Antoniades C, Benedetto U, et al. Mechanisms, consequences, and prevention of coronary graft failure. Circulation, 2017, 136(18): 1749-1764.
16. Kulik A, Chan V, Ruel M. Antiplatelet therapy and coronary artery bypass graft surgery: perioperative safety and efficacy. Expert Opin Drug Saf, 2009, 8(2): 169-182.
17. Deo SV, Dunlay SM, Shah IK, et al. Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis. J Card Surg, 2013, 28(2): 109-116.
18. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol, 2013, 112(10): 1576-1579.
19. Mannacio VA, Di Tommaso L, Antignan A, et al. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypaSS occlusion After off-pump procedures) randomised study. Heart, 2012, 98(23): 1710-1715.
20. Saw J, Wong GC, Mayo J, et al. Ticagrelor and aspirin for the prevention of cardiovascular events after coronary artery bypass graft surgery. Heart, 2016, 102(10): 763-769.
21. Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med, 2015, 372(19): 1791-1800.
22. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med, 2009, 361(11): 1045-1057.
23. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol, 2011, 57(6): 672-684.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Ticagrelor plus aspirin versus clopidogrel plus aspirin on graft patency after coronary artery bypass graft surgery: A randomized controlled trial

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