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Optimal antiplatelet strategy following coronary artery bypass grafting: a meta-analysis
  1. Ankit Agrawal1,
  2. Ashwin Kumar1,
  3. Muhammad Majid1,
  4. Osamah Badwan1,
  5. Aro Daniela Arockiam1,
  6. Joseph El Dahdah1,
  7. Alveena B Syed1,
  8. Mary Schleicher2,
  9. Grant W Reed1,
  10. Paul C Cremer1,
  11. Brian P Griffin1,
  12. Venu Menon1,
  13. Tom Kai Ming Wang1
  1. 1 Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2 Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
  1. Correspondence to Dr Tom Kai Ming Wang, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH 44195, USA; wangt2{at}


Objective Coronary artery bypass grafting (CABG) is an established revascularisation strategy for multivessel and left main coronary artery disease. Although aspirin is routinely recommended for patients with CABG, the optimal antiplatelet regimen after CABG remains unclear. We evaluated the efficacies and risks of different antiplatelet regimens (dual (DAPT) versus single (SAPT), and dual with clopidogrel (DAPT-C) versus dual with ticagrelor or prasugrel (DAPT-T/P)) after CABG.

Methods We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and performed a comprehensive literature search using PubMed, Ovid Medline, Ovid Embase and Cochrane Central Register of Controlled Trials. Data were extracted and pooled using random-effects models and Review Manager (V.5.4).

Results Among the 2970 article abstracts screened, 215 full-text articles were reviewed and 38 studies totaling 77 447 CABG patients were included for analyses. DAPT compared with SAPT was associated with significantly lower all-cause mortality (OR 0.65 with 95% CI 0.50 to 0.86; p=0.002), cardiovascular mortality (OR 0.53, 95% CI 0.33 to 0.84; p=0.008), and major adverse cardiac and cerebrovascular events (MACCE) (OR 0.68, 95% CI 0.51 to 0.91; p=0.01), but higher rates of major (OR 1.30, 95% CI 1.08 to 1.56; p=0.007) and minor bleeding (OR 1.87, 95% CI 1.28 to 2.74; p=0.001) after CABG. DAPT-T/P compared with DAPT-C was associated with significantly lower all-cause (OR 0.43, 95% CI 0.29 to 0.65; p≤0.0001) and cardiovascular mortality (OR 0.44, 95% CI 0.24 to 0.80; p=0.008), and no differences on other cardiovascular or bleeding outcomes after CABG.

Conclusion In patients with CABG, DAPT compared with SAPT and DAPT-T/P compared with DAPT-C were associated with reduction in all-cause and cardiovascular mortality, especially in patients with acute coronary syndrome. Additionally, DAPT was associated with reduction in MACCE, but higher rates of major and minor bleeding. An individualised approach to choosing antiplatelet regimen is necessary for patients with CABG based on ischaemic and bleeding risks.

  • meta-analysis

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Twitter @AnkitAgrawalMD, @JeldahdahMD, @GrantReedMD

  • Contributors AA and TKMW were involved in the conceptualisation and design of the study. MS was involved in initial data synthesis, screening and extraction. AA, AK, MM, OB, ADA and ABS were involved in data screening and collection. AA conducted the statistical analysis. AA, AK and JED were involved in the manuscript writing. GR, PCC, BG, VM and TKMW were involved in the supervision, editing and final review of the manuscript. TKMW is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.