DAPT with ticagrelor after CABG confers similar outcomes to aspirin alone at 1 year
Click Here to Manage Email Alerts
At 1 year, aspirin plus ticagrelor after CABG was associated with similar saphenous vein graft occlusion, graft failure and bleeding compared with aspirin alone, according to results from the POPular CABG trial.
There was no reduction in saphenous vein graft occlusion rates with the addition of ticagrelor (Brilinta, AstraZeneca) to standard aspirin compared with aspirin plus placebo, according to the findings, which were presented at the European Society of Cardiology Congress and published in Circulation.
“We know that approximately 15% of all saphenous vein grafts occlude in the first year after coronary artery bypass grafting. We also know that SVG occlusions are associated with adverse events, such as angina pectoris, myocardial infarction, and long-term mortality,” Laura M. Willemsen, MD, of the department of cardiology at St. Antonius Hospital in Nieuwegein, The Netherlands, said during a presentation. “Therefore, the idea was raised that better platelet inhibition could also provide better SVG patency. Ticagrelor is already recommended for the medical treatment of acute coronary syndromes and the ESC guidelines already recommend resuming ticagrelor in patients who underwent CABG for ACS. Therefore, we performed the POPular CABG trial. This had the hypothesis that the addition of ticagrelor to standard aspirin after CABG will reduce the rate of SVG occlusions.”
For this randomized, double-blind, placebo-controlled trial, investigators enrolled 443 patients who underwent CABG and randomly assigned them to receive DAPT with ticagrelor plus aspirin or aspirin plus placebo. The primary outcome was rate of saphenous vein graft occlusion at 1 year, assessed with cardiac CT angiography or coronary angiography. The secondary outcomes were a composite of saphenous vein graft failure that included saphenous vein graft occlusion, revascularization, MI in the myocardial area supplied by the saphenous vein graft or sudden death. Bleeding events at 30 days and 1 year were also assessed.
Ticagrelor vs. placebo after CABG
Researchers observed that at 1 year, there was no significant difference between the ticagrelor or placebo groups for saphenous vein graft occlusion (51 events vs. 43 events; OR = 1.29; 95% CI, 0.73-2.3).
There was also no significant difference between treatment groups in the rate of saphenous vein graft failures (10.5% vs. 91.%; OR = 1.22; 95% CI, 0.72-2.05) or in bleeding events at 30 days (2.4% vs. 1.6%; OR = 1.53; 95% CI, 0.43-5.41) or at 1 year (3.6% vs. 2.4%; OR = 1.52; 95% CI, 0.54-4.28).
“In POPular CABG, no discernible effect of adding ticagrelor to aspirin on SVG patency could be found in the ACS subgroup, although the trial was not powered to detect differences in subgroups. Further, it is possible that ticagrelor has not only antithrombotic but also pleiotropic benefits that have no relation to SVG patency,” Willemsen and colleagues wrote in Circulation. “Our trial does not refute the advice of the guidelines to continue ticagrelor in patients undergoing CABG for ACS. On the other hand, possible advantages of ticagrelor should be weighed against potential adverse effects, such as dyspnea and an increase in bleeding risk. Therefore, further research is needed to determine the most appropriate treatment after CABG, not only to optimize graft patency but also to improve clinical outcomes.”
Aggressive therapy not needed
“While it is attractive to propose that more aggressive antiplatelet therapies could improve SVG patency, my belief is that this study, in addition to the other studies cited in the text with similar negative findings from adding antiplatelet agents to aspirin, lays this approach to rest,” Steven Goldman, MD, C. Leonard Pfeiffer Endowed Professor of Cardiovascular Research at the Sarver Heart Center at the University of Arizona in Tucson, wrote in a related editorial in Circulation.
References:
- Willemsen L, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.120.050749.
- Goldman S. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.120.050879.
Collapse
Willemsen et al. Latest Randomized Results on Antiplatelet Therapy. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).
Click Here to Manage Email Alerts