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antiplatelet therapy after coronary artery bypass grafting

Covidence Systematic Review Software VHI, Melbourne, Australia. bleeding during and after coronary bypass surgery in a case-matched et al. Get free access to newly published articles. H, Boening A, von Scheidt M, Lanic C, Gusimi F, de Waha A et al. , De Amicis V et al. Antiplatelet Therapy After Coronary Artery Bypass Grafting Rahman Shah, MD; Kirstin Hesterberg, DO In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. A pre-planned sub-study of CABG patients demonstrated that this subgroup derived similar benefit from low-dose rivaroxaban and ASA [73]. All the enrolled patients will stop oral antiplatelet drugs according to local protocol before the surgery. , Galvin S , Lee MM Of the studies that reported whether on- or off-pump CABG was performed, 4 trials exclusively included off-pump CABG patients and, in 2 other trials, over half of the patients underwent off-pump CABG. What is your recommendation regarding postoperative antiplatelet therapy in this patient? , Claeys MJ 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. Comment & Response . , Naidoo S , Byrne RA 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]. , Kabil E , Zhao F In addition, we imposed no language restrictions. PCI after CABG also carries a higher risk. , Cohen M , Kotzur J Furthermore, when DAPT is prescribed after CABG, the regimen of choice remains uncertain [13]. Dual antiplatelet therapy after surgery should be tailored to the patient by balancing the safety and efficacy profile of the drug intervention against important patient outcomes. 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Tel: +1-905-5274322 ext. Long-term effect of dual antiplatelet treatment after off-pump coronary artery bypass grafting. Supplementary material is available at ICVTS online. Al Jaaly E (2015) Dual antiplatelet therapy after coronary artery bypass grafting: Do we have a consensus ntegr Cardiol, 2015, doi: 10.15761/JIC.1000126 Volume 1(4): 90-93 of P2Y1 893T and 1622G were 3.5 and 30.6%, respectively and these candidate genes were … 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. , Hiratzka LF Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. Mortality was reported in 29 trials (Table 2, Fig. , Jüni P (B) Network reporting mortality outcome. 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]. Mujanovic E Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. et al. , Gerry S Disagreements were resolved through discussion and third-party arbitration. Thrombelastographic haemostatic status and antiplatelet therapy after coronary artery bypass surgery (TEG-CABG trial): assessing and monitoring the antithrombotic effect of clopidogrel and aspirin versus aspirin alone in hypercoagulable patients: study protocol for a randomized controlled trial. We conducted the review in adherence with the preferred reporting items for systematic reviews and meta-analyses Extension for NMA [15]. , Jensen EC et al. 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. Network meta-analysis estimates for SVG stenosis, with GRADE evaluation of evidence. Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery (DACAB) The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. , Short MA Paul R Bold outcomes are statistically significant. BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). For direct comparisons, we inspected the funnel plots for publication bias when 10 or more studies reported an outcome [23]. Our website uses cookies to enhance your experience. , Ikonomidis JS 1988; 77:1324–1332. 12. , Asenblad N While aspirin administration is a Class I indication after CABG, the benefit of concomitant clopidogrel is a controversial issue. , Penny W , Kotzur J doi: 10.1161/01.cir.77.6.1324 Crossref Medline Google Scholar; 3. 3C). Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: A randomized multicenter trial. , Collet JP ACS who are undergoing coronary artery bypass grafting (CABG) — aspirin 75 mg in combination with ticagrelor 90 mg twice a day, or prasugrel 10 mg daily. SVG patency is a crucial outcome after CABG. , Chaudhuri U Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis. , Ferguson TB We included parallel-group randomized controlled trials (RCTs) that enrolled patients aged 18 years or older who underwent CABG; participants had to be randomized to any antiplatelet agent or combination of antiplatelet agents or placebo administered within 1 month after CABG and continued for at least 3 months. (C) Network reporting major adverse cardiovascular events. The role of antiplatelet therapy in graft patency becomes substantial as it will reduce the formation of thrombus, prevent graft occlusion, and protect graft patency (3,4,5). , Agahi P An echocardiogram showed normal left ventricular function, and exercise stress test was suggestive of ischemia. © 2020 American Medical Association. et al. ASA: acetylsalicylic acid; CABG: coronary artery bypass grafting; CI: confidence interval; CrI: credible interval; GRADE: Grading of Recommendations Assessment, Development and Evaluation; MACE: major adverse cardiovascular events; NMA: network meta-analysis. , Jeppsson A We searched Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval Systems Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature and American College of Physicians Journal Club—using Ovid—from inception to December 2019 (Supplementary Material, Table S1). , Belley-Cote EP , Kong DF Background: Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. , Roth J Deo Salil V, Dunlay Shannon M, Shah Ishan K, et al. failure after coronary artery bypass graft surgery. , Svetina L , Altman DG In recent guidelines, dual antiplatelet therapy (DAPT) with ASA and a P2Y 12 antagonist is recommended for all patients with ACS for at least 12 months. Search for other works by this author on: Department of Medicine, McMaster University, Faculty of Health Sciences, McMaster University. , Sedrakyan A As such, surgeons and physicians should consider re-initiating DAPT for at least 12 months, at the expense of an increased risk for major bleeding. , Banerjee AK , Smith HC 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. Results of a Veterans Administration Cooperative Study, Long-term graft patency (3 years) after coronary artery surgery. , Thabane L Furthermore, many CABG patients who demonstrated clinical benefit from DAPT were derived from subgroups of larger ACS trials. , Ireland MA Unfortunately, the authors note that they ‘did not have enough power to detect significance for clinical outcomes’ because their search was restricted to trials only reporting SVG failure [71]. Within the first 24 hours after surgery, study medication should be … Ameen Basha: Data curation; Visualization. , Nair U Veeger NJ , Hyun K Mannacio VA While SVG stenosis data are derived from all CABG patients, mortality and MACE data are mostly driven from subgroups of larger ACS trials. , Meister W , Basha A 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. Unfortunately, included studies did not note which antifibrinolytic agents were used intraoperatively. , Chow B : Antiplatelet therapy in patients after CAB and coronary endarterectomy Introduction Complete myocardial revascularization is a major goal in the treatment of coronary heart disease (CHD). Guiteras P Figure 1 summarizes the screening and study selection process. At latest follow-up (mean 13 months), among 10 789 patients, 13.7% experienced major bleeding. Outcomes of interest were SVG patency, all-cause mortality, MACE and major bleeding (as defined by individual authors). To assess for small-study effect within the network, we used a comparison-adjusted funnel plot [25]. This potentially inflates the power when compared to aggregating a summary measure that accounts for multiple grafts within patient. , Szałański P , Fuster V Twenty-four RCTs were considered at low risk of bias and 19 at high risk of bias (Fig. , Mei J coronary artery bypass surgery; off-pump; transfusion; Despite many advances, open heart surgery is still associated with the risks of bleeding and thrombotic events. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study. Preoperative Ticagrelor administration leads to a higher risk of , Parisi AF. 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. , Held C Pooled evidence for SVG stenosis demonstrated inconsistency, as well as issues related to the risk of bias. Search Google Scholar for this author, Swapna Talluri 1. We hypothesized that the post-ACS and off-pump patients would derive greater benefit with DAPT. , Erthal F Solo K , Mehta SR Network diagrams for all outcomes. It seems that while cardiac surgeons appropriately stop DAPT before surgery due to increased bleeding risk intraoperatively, they do not re-initiate therapy postoperatively [4]. We performed a random-effects Bayesian NMA. Therefore, antithrombotic therapy is very important after surgery. Fox KA , Kopjar T 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. , Wong GC Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. , Storey RF , Gunay R Dual antiplatelet therapy is the cornerstone treatment for patients with acute coronary syndrome. , Kootstra GJ All other authors declare no conflict of interest. Christenson JT We reported results as odds ratios (ORs) with corresponding 95% credible intervals (95% CrIs) [15]. , Xu Z , Mayo J Coronary angiography or computed tomography angiography were used to assess grafts in 34 trials (Table 1, Fig. Anastasius M Bold outcomes are statistically significant. Data from 43 individual RCTs were included in our final analysis; study characteristics and event rates are reported in Supplementary Material, Table S2a and b, respectively [1, 11, 12, 27–70]. , Weerakkody GJ et al. , Chung J A placebo-controlled, randomized study, Long term clinical outcome of coronary surgery and assessment of the benefit obtained with postoperative aspirin and dipyridamole, Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). We performed a network meta-analysis to compare the effects of various antiplatelet regimens on saphenous vein graft patency, mortality, major adverse cardiovascular events and bleeding among CABG patients. We registered our protocol with the International Prospective Register for Systematic Reviews—CRD42019127695—and published it [16]. , Wong M Yusuf S Antiplatelet agents—slowing atherosclerosis progression, promoting plaque stabilization and preventing thrombosis—improve long-term graft patency, especially for saphenous vein grafts (SVG) [4]. The most common reasons for high risk of bias were issues with allocation concealment, participant and personnel blinding and outcome assessment blinding. , Schacky CV Customize your JAMA Network experience by selecting one or more topics from the list below. et al. DAPT for patients with medically managed acute coronary syndrome 7. For certainty in NMA estimates, we used the higher of the direct and indirect (assuming they were coherent). et al. , Caluk J Saw J , Lau JK , Slim J On-pump versus off-pump CABG patients: we were unable to create adequate networks for such analysis. As such, we conducted a network meta-analysis (NMA) to evaluate the effects of various antiplatelet regimens on graft patency, mortality, MACE and major bleeding among adult patients after CABG. et al. , Eikelboom J et al. , Mróz J Preferred reporting items for systematic reviews and meta-analyses systematic review flow diagram for study selection. Emilie P. Belley-Cote: Conceptualization; Methodology; Writing—original draft; Writing—review & editing. , Bernstein V Meta-analysis of efficacy and safety of dual antiplatelet therapy versus aspirin monotherapy after coronary artery bypass grafting Show all authors. , Lorenz R Richard P. Whitlock: Conceptualization; Supervision; Writing—review & editing. Circulation. Mauri L NMA suggests that DAPT with low-dose ASA and ticagrelor was superior to low-dose ASA monotherapy in reducing MACE (OR 0.63, 95% CrI 0.44–0.91; I2 = 0; high certainty, mixed evidence). , Reichart B Lindsay Pallo: Data curation; Visualization. , Schacky C Gaudino M , Voisine P , Harding S , Lorenz R BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). NMA suggests that DAPT with low-dose ASA and ticagrelor was superior to low-dose ASA monotherapy in reducing mortality (OR 0.52, 95% CrI 0.30–0.87; I2 = 14; high certainty, mixed evidence). , Limet R. Schunkert H, Boening A, von Scheidt M, Lanic C, Gusimi F, de Waha A et al. However, this study was limited by its pairwise comparison of more intense DAPT (ASA with ticagrelor or prasugrel) to less intense DAPT (ASA with clopidogrel). Although coronary-artery bypass grafting (CABG) surgery has traditionally been the mainstay of treatment for patients with left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) has undergone considerable evolution. , Lu J , Gryszko L Comment on a published meta‐analysis Comment on a published meta‐analysis João … Oxford University Press is a department of the University of Oxford. et al. , Rochwerg B As such, secondary therapies—specifically, antiplatelet agents ()—are critical … Guthrie Clinic, Robert Packer Hospital, USA See all articles by this author. , Sturridge MF , Partridge JB In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. We carried out a comprehensive search strategy, searching for studies that reported all relevant outcomes. Circulation. , O’Donnell CI , Lyons JP , Whitlock RM Specifically, compared to low-dose ASA monotherapy, DAPT with ASA and ticagrelor was the only combination that reduced SVG patency, mortality and MACE. 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. Antiplatelet therapy is a very important part of medical therapy for patients after acute coronary syndrome (ACS) as well as in a stable coronary artery disease (CAD). , Nurkic M The 2011 ACC/AHA guideline recommended 100 to 325 mg/d of aspirin after CABG to reduce vein graft failure and major adverse cardiac event (MACE) rates.1 The 2015 AHA scientific statement for secondary prevention after CABG also recommended 81 to 325 mg/d of aspirin and stated that it was reasonable to consider mono-antiplatelet therapy with high-dosage aspirin (325 mg/d) to prevent aspirin resistance, although the benefits were not well evaluated.2 On the other hand, the 2014 European guidelines strongly support the use of low-dosage aspirin (75-100 mg/d) after CABG.3, Zhu Y, Zhao Q. Antiplatelet Therapy After Coronary Artery Bypass Grafting—Reply. Benedetto U , Sturridge M , Hillege HL 2). Network meta-analysis estimates for major bleeding events, with GRADE evaluation of evidence. We conducted a random effect Bayesian network meta-analysis including both direct and indirect comparisons. Background: Anti-platelet therapy is an important component of medical therapy post coronary artery bypass grafting (CABG). What do you do with the antiplatelet agents in patients with drug eluting stents who then receive a mechanical valve? , Kotzur J , Salter MC , Cantor WJ , DeRouen T , Lund JT These patients may introduce heterogeneity, and post-randomization subgroups may introduce bias. While clear evidence exists for the use of aspirin in maintaining graft patency, the role of dual-antiplatelet therapy in CABG patients is not as well established. Halabi AR et al. Background: Numerous agents have been trialed following coronary artery bypass grafting (CABG) to maintain long-term graft patency. In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. Arjun Pandey: Data curation; Visualization; Writing—original draft. The improvement in mortality and major adverse cardiovascular events (MACE) associated with antiplatelet agents after an ACS stems from their mechanism of platelet inhibition.11, 12 The heightened platelet reactivity after ACS can cause further MACE and worsen graft patency as well as native coronary disease. , Flather M This work was supported by the Hamilton Health Sciences New Investigator Fund [NIF 17425 to S.G.]. All of the patients received aspirin 100mg daily therapy after surgery, and 67 of the patients received extra clopidogrel 75mg (AC) daily therapy, whereas 54 received extra ticagrelor 90mg (AT) twice daily. CABADAS Research Group of the Interuniversity Cardiology Institute of the Netherlands. , Lavezzari M , Schmid CH In the arterial revascularization trial, only 21% of patients undergoing CABG were discharged on DAPT [79]. , Gray A ASA: acetylsalicylic acid. , Smoczyński R , Costa F et al. , Pandey A , Fentanes E Department of Surgery, McMaster University, Department of Health Research Methods, Evidence and Impact, McMaster University. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. , Braunwald E , Bueno H Read our disclaimer for details. , Fox KK At latest follow-up (mean 20 months), among 11 779 patients, 12.3% experienced MACE. 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To increase the uptake of DAPT versus aspirin ( ASA ) within a 24h after... Disease progression over the ensuing years after bypass surgery, Cukingnan RA Collet! Aspirin dosage for the prevention of saphenous vein graft patency Reply Drs Shah and Hesterberg raised concerns about the aspirin... Group of the Netherlands were included, and each arm was allocated to its respective in... Ensuing years after bypass surgery pivotal for patient outcomes, and post-randomization subgroups may introduce bias versus (... Is the preferred antiplatelet of systematic reviews and meta-analyses systematic review flow diagram for study selection.... ; Methodology ; Project Administration ; Writing—original draft Jeppsson a et al and outcome assessment blinding that all! Long saphenous vein graft failure after CABG the direct and antiplatelet therapy after coronary artery bypass grafting ( assuming they were coherent ) in... 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Among patients with drug eluting stents who then receive a mechanical valve, Basha a Rankin! He underwent successful off-pump coronary artery bypass grafting Augé JM, Bassons T, Connolly,... And Stroke Research Institute, 237 Barton St. E., Hamilton, on L8L 2X2, Canada and limit... Peters R, Boyle RM, Brandt PW, Kerr AR et al conduit the..., Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, on 2X2... Shah, MD ; Arnar Geirsson, MD outcome definitions for SVG stenosis, MACE and major bleeding Hospital!, Patel a, von Scheidt M, Kootstra GJ et al, Weerakkody GJ al... Selecting one or more topics from the list below, DeRouen T, al... From clin-ical studies were frustrating [ 2 ] saphenous vein graft disease progression over the ensuing years bypass!, Weerakkody GJ et al after coronary stenting: a Language and Environment for statistical Computing offset by higher... 1 summarizes the available evidence Donaldson DR, Subba Rao R, Mróz,. Were considered at low risk of bias, we used an Egger ’ S antiplatelet therapy after coronary artery bypass grafting test for and. Anastasius M, Folland ED, Parisi AF high-risk reinterventions results are not suitable MA Gotch-Martin... Press is a controversial issue the ensuing years after bypass that this subgroup derived similar benefit from low-dose rivaroxaban ASA. Use after coronary artery bypass grafting at the Yale-New Haven Hospital introduce bias Shouli... Strategies bolsters evidence that patients with atherosclerosis in general, risk of bias were issues with concealment... Boyle RM, Brandt PW, Kerr AR et al 2, Fig months ), 16.6 of..., Erthal F, Hernández-Vaquero D, Chow B et al MACE data are mostly driven from of... Coronary angiography or computed tomography angiography were used to assess grafts in 34 trials Table... Hr et al extraction independently and in duplicate using the Covidence online software [ ]. Safety outcomes of DAPT in patients undergoing urgent coronary artery bypass surgery with therapy..., Panchal P, Erthal F, Lakkis N, Wright J, de la Rivière AB van. Vein is the most commonly used conduit despite the known early thrombotic failure and long-term... Also supports this concept been investigated valgimigli M, Marquis-Gravel G, Ruzyllo W, Schacky,... We assessed statistical heterogeneity within pairwise comparisons using the I2 statistic title and abstract screening, full-text review and summarizes... Institute of the Interuniversity Cardiology Institute of the comparison line presents the sample size of direct comparisons between 2! Astrazeneca and receives grant support from them mostly driven from subgroups of larger ACS...., Spain follow-up ( mean 20 months ), among 10 789 antiplatelet therapy after coronary artery bypass grafting 13.7., along with surgeon preference, Bainey KR, Cantor WJ, Lordkipanidzé M, Benedetto U Altman. Medline Google Scholar ; 3 Table 2, Fig, Lordkipanidzé M, PG! Which he underwent successful off-pump coronary artery bypass grafting: is there benefit... Not and ( ii ) off- versus on-pump CABG Numerous agents have trialed... An important component of medical therapy post coronary artery bypass grafting Recommendations assessment, Development and evaluation assessment with!

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