Mid to long-term clinical outcomes improvement through dual antiplatelet therapy after coronary artery bypass grafting: Interpretation of DACAB-FE trial_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

QU Jianyu ¹ , CHEN Si ² ,  WANG Zhijian ³ , ZHOU Kang ⁴ ,  ZHAO Yuan ⁴ ,  DONG Ran ⁵ ,  SHI Dongmei ³ ,  DONG Nianguo ² ,  ZHENG Zhe ¹

1. Department of Cardiovascular Surgey, Fuwai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P. R. China;
2. Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, P. R. China;
3. Geriatric Cardiovascular Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P. R. China;
4. Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Changsha, 410011, P. R. China;
5. Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P. R. China;

Corresponding author：

WANG Zhijian, Email: nongfu1975@126.com; ZHAO Yuan, Email: drzhaoyuan@163.com; DONG Ran, Email: sbran8899@sina.com; SHI Dongmei, Email: ansdm2000@163.com; DONG Nianguo, Email: dongnianguo@hotmail.com; ZHENG Zhe, Email: zhengzhe@fuwai.com

Keywords：

Dual antiplatelet therapy; coronary artery bypass grafting; medium to long-term clinical outcome

DOI：

10.7507/1007-4848.202406070

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Coronary artery bypass grafting (CABG) is one of the most effective revascularization treatments for coronary heart disease. Secondary prevention strategies, which rely on antiplatelet and lipid-lowering drugs, are crucial after CABG to ensure the durability of revascularization treatment effects and prevent adverse cardiovascular and cerebrovascular events in the medium to long term. Previous research conducted by Professor Zhao Qiang's team from Ruijin Hospital of Shanghai Jiao Tong University, known as the DACAB study, indicated that dual antiplatelet therapy (DAPT, specifically ticagrelor+aspirin) after CABG can enhance venous graft patency. However, it remains uncertain whether DAPT can further improve the medium to long-term clinical outcomes of CABG patients. Recently, the team reported the medium to long-term follow-up results of the DACAB study, termed the DACAB-FE study, finding that DAPT administered after CABG can reduce the incidence of major cardiovascular events over five years and improve patients' medium to long-term clinical outcomes. This article will interpret the methodological highlights and significant clinical implications of the DACAB-FE study.

Citation： QU Jianyu, CHEN Si, WANG Zhijian, ZHOU Kang, ZHAO Yuan, DONG Ran, SHI Dongmei, DONG Nianguo, ZHENG Zhe. Mid to long-term clinical outcomes improvement through dual antiplatelet therapy after coronary artery bypass grafting: Interpretation of DACAB-FE trial. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(8): 1096-1100. doi: 10.7507/1007-4848.202406070 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.	Gaudino M, Antoniades C, Benedetto U, et al. Mechanisms, consequences, and prevention of coronary graft failure. Circulation, 2017, 136(18): 1749-1764.
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.	Zhu Y, Zhang W, Dimagli A, et al. Antiplatelet therapy after coronary artery bypass surgery: Five year follow-up of randomised DACAB trial. BMJ, 2024, 385: e075707.
5.	Schunkert H, Boening A, von Scheidt M, et al. Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: The TiCAB trial. Eur Heart J, 2019, 40(29): 2432-2440.
6.	Willemsen LM, Janssen PWA, Peper J, et al. Effect of adding ticagrelor to standard aspirin on saphenous vein graft patency in patients undergoing coronary artery bypass grafting (popular cabg): A randomized, double-blind, placebo-controlled trial. Circulation, 2020, 142(19): 1799-1807.
7.	Gaudino M, Di Franco A, Bhatt DL, et al. The association between coronary graft patency and clinical status in patients with coronary artery disease. Eur Heart J, 2021, 42(14): 1433-1441.
8.	Taggart DP, Benedetto U, Gerry S, et al. Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med, 2019, 380(5): 437-446.
9.	Gaudino M, Benedetto U, Fremes S, et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med, 2018, 378(22): 2069-2077.
10.	Sandner S, Redfors B, Angiolillo DJ, et al. Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery: A systematic review and meta-analysis. JAMA, 2022, 328(6): 554-562.
11.	Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-st-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation, 2016, 134(10): e123-e155.
12.	Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: The latest evidence. Curr Opin Cardiol, 2023, 38(6): 484-489.
13.	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: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2018, 39(3): 213-260.
14.	Writing Committee M, Lawton JS, Tamis-Holland JE, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol, 2022, 79(2): e21-e129.
15.	Gupta S, Belley-Cote EP, Agahi P, et al. Antiplatelet therapy and coronary artery bypass grafting: Analysis of current evidence with a focus on acute coronary syndrome. Can J Cardiol, 2019, 35(8): 1030-1038.
16.	Sandner S. Dual antiplatelet therapy after coronary artery bypass surgery. BMJ, 2024, 385: q1083.
17.	Sandner S, Gaudino M, Redfors B, et al. One-month DAPT with ticagrelor and aspirin for patients undergoing coronary artery bypass grafting: Rationale and design of the randomised, multicentre, double-blind, placebo-controlled ODIN trial. EuroIntervention, 2024, 20(5): e322-e328.
18.	Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med, 2009, 360(10): 961-972.
19.	Alexander JH, Hafley G, Harrington RA, et al. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT Ⅳ: A randomized controlled trial. JAMA, 2005, 294(19): 2446-2454.
20.	Desai ND, Cohen EA, Naylor CD, et al. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med, 2004, 351(22): 2302-2309.
21.	Goldman S, Sethi GK, Holman W, et al. Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: A randomized trial. JAMA, 2011, 305(2): 167-174.
22.	Shao QY, Wang ZJ, Ma XT, et al. Mortality of escalation and modulation antithrombotic therapy in coronary artery disease patients: A meta-analysis of randomized controlled trials. Thromb Haemost, 2023, 123(1): 108-117.
23.	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.
24.	中国冠状动脉旁路移植术后二级预防专家共识组, 中国医师协会心血管医师分会冠心病外科学组, 中华医学会胸心血管外科学分会冠心病外科学组. 中国冠状动脉旁路移植术后二级预防专家共识(2020版). 中华胸心血管外科杂志, 2021, 37(3): 193-201.Working Group of the Chinese Expert Consensus on Secondary Prevention after Coronary Artery Bypass Surgery, The Task Force for Coronary Artery Disease of Chinese Association of Cardiovascular Surgeons(CACS), The Task Force for Coronary Artery Disease of Chinese Society of Thoracic and Cardiovascular Surgery(CSTCVS).

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. Gaudino M, Antoniades C, Benedetto U, et al. Mechanisms, consequences, and prevention of coronary graft failure. Circulation, 2017, 136(18): 1749-1764.
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. Zhu Y, Zhang W, Dimagli A, et al. Antiplatelet therapy after coronary artery bypass surgery: Five year follow-up of randomised DACAB trial. BMJ, 2024, 385: e075707.
5. Schunkert H, Boening A, von Scheidt M, et al. Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: The TiCAB trial. Eur Heart J, 2019, 40(29): 2432-2440.
6. Willemsen LM, Janssen PWA, Peper J, et al. Effect of adding ticagrelor to standard aspirin on saphenous vein graft patency in patients undergoing coronary artery bypass grafting (popular cabg): A randomized, double-blind, placebo-controlled trial. Circulation, 2020, 142(19): 1799-1807.
7. Gaudino M, Di Franco A, Bhatt DL, et al. The association between coronary graft patency and clinical status in patients with coronary artery disease. Eur Heart J, 2021, 42(14): 1433-1441.
8. Taggart DP, Benedetto U, Gerry S, et al. Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med, 2019, 380(5): 437-446.
9. Gaudino M, Benedetto U, Fremes S, et al. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. N Engl J Med, 2018, 378(22): 2069-2077.
10. Sandner S, Redfors B, Angiolillo DJ, et al. Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery: A systematic review and meta-analysis. JAMA, 2022, 328(6): 554-562.
11. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-st-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation, 2016, 134(10): e123-e155.
12. Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: The latest evidence. Curr Opin Cardiol, 2023, 38(6): 484-489.
13. 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: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2018, 39(3): 213-260.
14. Writing Committee M, Lawton JS, Tamis-Holland JE, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol, 2022, 79(2): e21-e129.
15. Gupta S, Belley-Cote EP, Agahi P, et al. Antiplatelet therapy and coronary artery bypass grafting: Analysis of current evidence with a focus on acute coronary syndrome. Can J Cardiol, 2019, 35(8): 1030-1038.
16. Sandner S. Dual antiplatelet therapy after coronary artery bypass surgery. BMJ, 2024, 385: q1083.
17. Sandner S, Gaudino M, Redfors B, et al. One-month DAPT with ticagrelor and aspirin for patients undergoing coronary artery bypass grafting: Rationale and design of the randomised, multicentre, double-blind, placebo-controlled ODIN trial. EuroIntervention, 2024, 20(5): e322-e328.
18. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med, 2009, 360(10): 961-972.
19. Alexander JH, Hafley G, Harrington RA, et al. Efficacy and safety of edifoligide, an E2F transcription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery: PREVENT Ⅳ: A randomized controlled trial. JAMA, 2005, 294(19): 2446-2454.
20. Desai ND, Cohen EA, Naylor CD, et al. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med, 2004, 351(22): 2302-2309.
21. Goldman S, Sethi GK, Holman W, et al. Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: A randomized trial. JAMA, 2011, 305(2): 167-174.
22. Shao QY, Wang ZJ, Ma XT, et al. Mortality of escalation and modulation antithrombotic therapy in coronary artery disease patients: A meta-analysis of randomized controlled trials. Thromb Haemost, 2023, 123(1): 108-117.
23. 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.
24. 中国冠状动脉旁路移植术后二级预防专家共识组, 中国医师协会心血管医师分会冠心病外科学组, 中华医学会胸心血管外科学分会冠心病外科学组. 中国冠状动脉旁路移植术后二级预防专家共识(2020版). 中华胸心血管外科杂志, 2021, 37(3): 193-201.Working Group of the Chinese Expert Consensus on Secondary Prevention after Coronary Artery Bypass Surgery, The Task Force for Coronary Artery Disease of Chinese Association of Cardiovascular Surgeons(CACS), The Task Force for Coronary Artery Disease of Chinese Society of Thoracic and Cardiovascular Surgery(CSTCVS).

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Mid to long-term clinical outcomes improvement through dual antiplatelet therapy after coronary artery bypass grafting: Interpretation of DACAB-FE trial

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