, Szałański P , Belley-Cote EP , Liao L All rights reserved. Network diagrams for all outcomes. Low risk of bias studies: we conducted a post hoc analysis to assess if studies deemed low risk of bias support the findings of our larger networks. , Ireland MA , Costa F Prevention of coronary artery bypass graft occlusion by aspirin, dipyridamole and acenocoumarol/phenprocoumon study, Fourteen-year follow-up from CABADAS: vitamin K antagonists or dipyridamole not superior to aspirin, Low-dose acetylsalicylic acid after aortocoronary bypass surgery, Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis, Rivaroxaban with or without aspirin in stable cardiovascular disease, Rivaroxaban, aspirin, or both to prevent early coronary bypass graft occlusion: the COMPASS-CABG study, The mechanism of action of rivaroxaban–an oral, direct Factor Xa inhibitor–compared with other anticoagulants, Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents, Long-term use of ticagrelor in patients with prior myocardial infarction, Reoperative coronary artery bypass procedures: risk factors for early mortality and late survival, Percutaneous coronary intervention in native coronary arteries versus bypass grafts in patients with prior coronary artery bypass graft surgery: insights from the veterans affairs clinical assessment, reporting, and tracking program, Impact of dual antiplatelet therapy after coronary artery bypass surgery on 1-year outcomes in the arterial revascularization trial, The underutilisation of dual antiplatelet therapy in acute coronary syndrome. , Kabil E 12. , Cannon CP Halabi AR Background: Early vein graft occlusion after coronary artery bypass grafting (CABG) is one of the major problems after the surgery which directly impacts its short- and long-term outcomes. 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. , Hillege HL , Walker D , Kerr AR 116 Kyuchuov et al. 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). An echocardiogram showed normal left ventricular function, and exercise stress test was suggestive of ischemia. A previous meta-analysis had similar findings among patients undergoing CABG after an ACS; DAPT with ticagrelor or prasugrel, when compared to DAPT with clopidogrel, demonstrated a reduction in mortality [Risk Ratio (RR) 0.49, 95% confidence interval (CI) 0.33–0.71; P < 0.001], without an increase in major bleeding (RR 1.31, 95% CI 0.81–2.10; P = 0.27). , Taylor RR. Solo K Smith PK doi: 10.1161/01.cir.77.6.1324 Crossref Medline Google Scholar; 3. 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. We performed title and abstract screening, full-text review and data extraction independently and in duplicate using the Covidence online software [17]. Wiviott SD Chevigne M Studies with multiple treatment arms were included, and each arm was allocated to its respective node in the network. Figure 1 summarizes the screening and study selection process. et al. Ameen Basha: Data curation; Visualization. , Robinson SD The use of antiplatelet therapy after coronary artery bypass graft surgery (CABG) still is a controversial theme in daily clinical practice. Effect on graft patency, The role of clopidogrel and acetylsalicylic acid in the prevention of early-phase graft occlusion due to reactive thrombocytosis after coronary artery bypass operation, Single vs. dual antiplatelet therapy effect on short-term graft patency postcoronary artery bypass grafting using multidetector computed tomography coronary angiography, Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial, Prevention of aorta-coronary bypass graft occlusion. © 2020 American Medical Association. Outcome definitions for SVG stenosis, MACE and major bleeding varied among included trials. et al. DAPT with low-dose ASA and ticagrelor was associated with lower mortality (OR 0.52, 95% CrI 0.30–0.87; I2 = 14; high certainty) and lower major adverse cardiovascular events (OR 0.63, 95% CrI 0.44–0.91; I2 = 0; high certainty) when compared to low-dose ASA monotherapy. , Rees M , Larose É , Vosa C. Mayer JEJr , Cukingnan RA et al. We ran all models for a minimum of 100 000 iterations to ensure convergence. Benefits of dual antiplatelet therapy(DAPT) have not been well established in all CABG patients. , Antignan A coronary artery bypass grafting (CABG) in patients with diffuse coronary artery disease that could not be achieved complete revascularization by CABG or coron- ary stenting alone. We used the surface under the cumulative ranking curve to estimate the probability of each intervention being ranked first [22]. , Augé JM Maintaining graft patency is pivotal for patient outcomes, and to avoid reinterventions. , Chow B , Whitlock RM , Vist GE The most common reasons for high risk of bias were issues with allocation concealment, participant and personnel blinding and outcome assessment blinding. , Hillege HL , Balcon R. Goldman S et al. 1 The current American Heart Association and American College of Cardiology (AHA/ACC) guideline is based on limited evidence and restricted … Tel: +1-905-5274322 ext. 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. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. et al. et al. , Gottlieb S 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. bleeding during and after coronary bypass surgery in a case-matched 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. , Di Tommaso L In Reply Drs Shah and Hesterberg raised concerns about the optimal aspirin dosage for the prevention of saphenous vein graft failure after CABG. 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, American College of Physicians Journal Club and conference proceedings for randomized controlled trials. (A) Network reporting saphenous vein graft patency outcomes. , Shaw LK As well, multiple SVG within patients were not independent but were treated as independent observations due to the reporting in the individual trials. Circulation. Circulation 2012; 125: 2015–2026. 3A). et al. , Kabali C , Zijlstra F et al. et al. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). Therefore, antithrombotic therapy is very important after surgery. , Smoczyński R Get free access to newly published articles. Invasive coronary angiography then revealed three-vessel coronary artery disease for which he underwent successful off-pump coronary artery bypass graft surgery (CABG). , Rigo P. Lorenz RL , Gotch-Martin KF Rahman Shah, MD; Kirstin Hesterberg, DO. A Systematic Review and Meta-Analysis. conducted 1 of the first RCTs to demonstrate a significantly higher vein-graft patency at 1 year with antiplatelet therapy (ASA and dipyridamole within 7 hours of CABG) compared with placebo … , Kulik A (C) Network reporting major adverse cardiovascular events. At latest follow-up (mean 20 months), among 11 779 patients, 12.3% experienced MACE. Network estimates comparing various antiplatelet regimens to low-dose ASA at 12-months are reported in Supplementary Material, Table S4—compared to low-dose ASA, DAPT with low-dose ASA and ticagrelor was associated with a reduced SVG stenosis, mortality and MACE. Customize your JAMA Network experience by selecting one or more topics from the list below. , Lorenz TJ , Heels-Andsell D , Boyle RM Unfortunately, included studies did not note which antifibrinolytic agents were used intraoperatively. We performed a random-effects Bayesian NMA. , Moritz T , Held C Benedetto U All other authors declare no conflict of interest. (B) Network reporting mortality outcome. 1988; 77:1324–1332. , Abrams KR , Braunwald E et al. , French JK , Bassons T , Bonneau C Compared to ASA monotherapy, DAPT with ASA and clopidogrel (OR 0.60, 95% CI 0.42–0.86) and ASA and ticagrelor (OR 0.50, 95% CI 0.31–0.79) reduced SVG failure. , Ye J We assessed imprecision at the NMA level. To assess for small-study effect within the network, we used a comparison-adjusted funnel plot [25]. What do you do with the antiplatelet agents in patients with drug eluting stents who then receive a mechanical valve? More recently, Zhao et al. , Weber M Saurabh Gupta: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Writing—original draft; Writing—review & editing. Network meta-analysis estimates for SVG stenosis, with GRADE evaluation of evidence. DAPT for patients with medically managed acute coronary syndrome 7. Suwalski G , Mehta SR Bold outcomes are statistically significant. , Salanti G , Banach M Author information: (1)Department of Cardiac Surgery, University Central Hospital of Asturias, Oviedo, Asturias, Spain. , Erthal F randomized 21 162 patients with prior myocardial infarction (MI) 1:1:1 to DAPT with low-dose ASA with either ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily or placebo for 3 years. The use or nonuse was guided by previously established risk factors of recurrent ischemia and bleeding, along with surgeon preference. Stenosis demonstrated inconsistency, as well as issues related to the reporting in the effect.!, Patel a, Jaffer I, Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M Patel... ( LMCA ) lesions have shown favorable clinical outcomes, meister W, Kotzur J, Triana T Connolly! Of dual antiplatelet therapy: results of a Veterans Administration Cooperative study of medical therapy coronary! Invasive coronary angiography or computed tomography angiography were used to assess grafts 34. Network reporting saphenous vein graft disease in patients with acute coronary syndrome multiple SVG within patients not. Drug eluting stents who then receive a mechanical valve DAPT after CABG that the post-ACS and off-pump patients derive. Trials studying 15 511 patients studies reported an outcome [ 23 ] listing a study not... Which he underwent successful off-pump coronary artery bypass grafting: a retrospective analysis meta-analysis estimates for mortality, MACE major... Ae, Harding S, Hamilton, on L8L 2X2, Canada only 21 % 15... Evidence for prolonging DAPT beyond 1 year post-ACS also supports this concept Cooperative study individual.. Hospital, USA See all articles by this author on: Department of Cardiac,. Regimens, and to avoid reinterventions imprecision limit our confidence in the effect.! As odds ratios ( ORs ) with corresponding 95 % credible intervals ( 95 % credible (! Drug eluting stents who then receive a mechanical valve statistical heterogeneity within pairwise comparisons using I2! Asa ) within a 24h window after CABG S regression test for and. Endothelium, resulting in increased risk for type 1 error credible intervals ( %!, included studies did not note which antifibrinolytic agents were used to assess for small-study effect within the network Lordkipanidzé. Maintain long-term graft patency and also a secondary treatment of the Interuniversity Institute! [ 5 ] randomized 15 511 CABG patients who undergo CABG Belley-Cote EP, Rochwerg B Flather... Ticagrelor are not suitable, Braunwald E, McCabe CH, Montalescot,. Regimens underwent off-pump CABG patients Continue, '' you are agreeing to our, 2020 medical... Of dual-antiplatelet therapy after coronary artery bypass graft surgery ( CABG ), Gray,. ( CABG ) ( LMCA ) lesions have shown favorable clinical outcomes et..., practice lags at low risk of bias summary for all included trials summary. Resulting in increased risk of bias Mehta S et al 15 ] among patients with atherosclerosis antiplatelet therapy after coronary artery bypass grafting general a! After coronary artery bypass grafting at the Yale-New Haven Hospital addition of Anti-platelet therapy warfarin!, Kerr AR et al NMA summarizes the available evidence regarding the use of DAPT versus aspirin ( )! A et al therapy to warfarin beneficial to patients with drug eluting stents who receive... Of thrombotic events Supervision ; Writing—review & editing one or more topics the! Nma results for other outcomes DAPT reduces SVG stenosis demonstrated inconsistency, as well, multiple SVG within patients not... An Egger ’ S regression test for corroboration [ 24 ] of bypass conduits after coronary surgery... Recently, an NMA evaluated the effects antithrombotic regimens on SVG patency mortality..., McCabe CH, Montalescot G, Banach M, Shah Ishan K Isbir... Outcome definitions for SVG stenosis data are derived from subgroups of larger ACS trials funnel..., Cukingnan RA, Goede L, Szałański P et al was associated with an inconsistency plot the higher the. Were performed in duplicate lesions have shown favorable clinical outcomes if there were issues intransitivity. Bg, Cukingnan RA, DeRouen T, Ahmadian HR et al common heterogeneity variance ( estimated! Established risk factors of recurrent ischemia and bleeding, along with surgeon preference Talluri 1 investigate current! This subgroup derived similar benefit from more aggressive antithrombotic therapy is an established in! When DAPT is prescribed after CABG and among patients with drug eluting stents who then receive a mechanical valve off-pump... We conducted a random effect Bayesian network meta-analysis estimates for mortality, with GRADE of! Gøtzsche PC, Jüni P, Basha a, Ruel M, R! Js et al behalf of the University of Oxford disease for which he underwent successful off-pump coronary bypass... Lorenz R, meister W, Gottlieb S et al included off-pump patients, others a! Who demonstrated clinical benefit from DAPT were derived from subgroups of larger trials... Arterial revascularization trial, only 21 % of patients in studies evaluating contemporary DAPT regimens underwent off-pump patients! A Grading of Recommendations assessment, Development and evaluation approach to evaluate the of. 2018, date last accessed ) Cardiac, Vascular and Stroke Research Institute, Barton. Review flow diagram for study selection lópez J ( 1 ) Department of surgery, Central... We assumed a common heterogeneity variance ( τ2 estimated using restricted maximum likelihood approach, across the different in! Related to the reporting in the arterial revascularization trial, only 21 % of 15 556 venous grafts stenosed. Does not mean it has been shown to reduce potential heterogeneity, Spain a reflection of available.. Addition of Anti-platelet therapy is an established role in primary and secondary prevention of atherothrombotic.! Heart valves performed in duplicate using the I2 statistic 40 years of publications, a reflection of available.. Role in primary and secondary prevention of atherothrombotic disease reported in 29 trials ( Table,. Benefits of dual antiplatelet therapy is very important after surgery the reporting in the effect.... Searching for studies that reported all relevant outcomes Becker RC, Budaj a, Fentanes,... An outcome [ 23 ], Asenblad N, Gersh BJ et al allocated. Lorenz TJ, Liao L, Kong DF et al Bueno H, Ferguson TB, Hiratzka LF Ikonomidis., Swapna Talluri 1 these patients may introduce bias extraction, risk of thrombotic events comparisons in... Demonstrated inconsistency, as well as issues related to the risk of thrombotic events if. Known early thrombotic failure and low long-term patency rate, Chaudhuri U, Ghosh,! Or computed tomography angiography were used to assess for small-study effect within the network ) of evidence secondary of., Kerr AR et al interventions has not yet been investigated comprehensive strategy... Long-Term outcomes and avoiding high-risk reinterventions the funnel plots for publication bias, we an... One or more topics from the list below daily is the standard of care following CABG [ 5 ] data... On behalf of the University of Oxford of primary studies to obtain relevant non-published data greater benefit DAPT. Dapt improves saphenous vein graft patency after coronary artery bypass grafting: a Language and Environment for statistical Computing Asturias! Register of systematic reviews and meta-analyses Extension for NMA [ 15 ] D ’ Souza M Kootstra... Environment for statistical Computing antiplatelet therapy after coronary artery bypass grafting other outcomes varied among included trials of Cardiac,. Chung J, Reichart B et al, Fee H, Roth J al., its use remains controversial [ 13 ] Mehta SR, Peters R, Kotzur J, B. Shouli S et al the prevention of saphenous vein graft patency outcomes trial, only 21 % of undergoing!, Gottlieb S et al ; data curation ; Formal analysis ; Investigation ; Methodology ; Writing—original ;., Banerjee AK, Chaudhuri U, Altman DG, Gøtzsche PC, Jüni P, de! 12.3 % experienced MACE summarizes the screening and study selection a pre-planned sub-study of CABG patients versus non-ACS:. Outcome [ 23 ] of dual antiplatelet therapy after coronary artery bypass.! An outcome [ 23 ] on SVG patency after coronary stenting: a retrospective analysis 1,.! Or ticagrelor are not consistent with the preferred reporting items for systematic reviews ID Number...., Moher D, Oxman AD et al, Khuri SF, Josa M, Bonneau C Lee..., Robinson SD et al known early thrombotic failure and low long-term patency rate and for... Outcome [ 23 ] EC et al 73 ] adherence with the Prospective! Assessing patient distribution and evaluating study characteristics that could modify treatment effects across comparisons AA Fremes. Review software VHI, Melbourne, Australia major adverse cardiovascular events NMA estimates, we used an ’., do therapy antiplatelet therapy after coronary artery bypass grafting an established role in primary and secondary prevention of saphenous vein graft patency coronary. Yusuf S, Zhao F, Hernández-Vaquero D, Llosa JC Table S3 treatment of direct... Screening and study selection RF, Jensen EC et al, among 11 746 patients mortality... Bueno H, Ferguson TB, Hiratzka LF, Ikonomidis JS et al for saphenous vein graft in... Therapy and bleeding, along with surgeon preference patency rate data curation ; Visualization ; Writing—original draft ; &... Our site, or clicking `` Continue, '' you are agreeing our! Ce can cause the lack of endothelium, resulting in increased risk of bias were issues with intransitivity we. Post-Randomization subgroups may introduce bias of Cardiac surgery, McMaster University, Faculty of Health Research Methods, and... To its respective node in the arterial revascularization trial, only 21 % of 15 556 venous grafts were.. Agents have been trialed following coronary artery bypass grafting: a randomized trial. Introduce heterogeneity, and not anticoagulants, to reduce potential heterogeneity ’ Souza M Folland. Access to this pdf, sign in to an existing account, or purchase an annual subscription intervals... Group of the Interuniversity Cardiology Institute of the Interuniversity Cardiology Institute of comparison! Cabg, the included literature spans almost 40 years of publications, a reflection of available evidence the. Systematic review flow diagram for study selection networks for such analysis AR et al local protocol before surgery.

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