ANTI-PLATELET THERAPY AFTER CORONARY ARTERY BYPASS GRAFTING: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS
CCC ePoster Library. Gupta S. 10/26/19; 280551; 316
Dr. Saurabh Gupta
Dr. Saurabh Gupta
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Abstract
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BACKGROUND: Aspirin (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), has not been well-established in all CABG patients. We performed a network meta-analysis (NMA) to compare the effects of various antiplatelet therapy regimens on saphenous vein graft (SVG) patency, all-cause mortality, and bleeding outcomes amongst adult patients following CABG.

METHODS AND RESULTS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC and grey literature sources (AHA, ACC, ESC and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. Screening, data extraction, risk of bias (ROB) and GRADE were performed in duplicate. The NMA was performed with R, the results reported as odds ratios, and the I2 value was reported for heterogeneity. We used the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. We included 41 RCTs comprising 14,014 patients. For reduction in SVG stenosis and obstruction at one-year, therapy with ASA and ticagrelor ranked first. Compared to ASA monotherapy, DAPT with ASA and ticagrelor statistically significantly reduced stenosis (odds ratio [OR] 0.41, 95% credible interval [CrI]: 0.25,0.70). For reduction in all-cause mortality at one-year, monotherapy with clopidogrel was ranked first. Compared to ASA only, clopidogrel statistically significantly reduced mortality (OR 2.0e-09, 95%CrI: 2.7e-26, 1.0). Meanwhile, DAPT with ASA and ticagrelor demonstrated a direction towards lower all-cause mortality at one-year (OR 0.38, 95%CrI: 0.013, 5.8) when compared to ASA monotherapy, but failed to reach statistical significance. For major bleeding events at one-year, placebo or no antiplatelet therapy ranked first. However, compared to standard of care (ASA monotherapy), DAPT with ASA and ticagrelor or ASA and clopidogrel was not associated with a statistically significant increase in bleeding. Heterogeneity for SVG stenosis, and bleeding was low (I2 ≤25%), and high for mortality (I2 >50%).

CONCLUSION: Our work is the largest and most comprehensive quantitative synthesis of RCT data regarding the use of antiplatelet therapy following coronary artery bypass grafting surgery. The network ranked ASA and ticagrelor first for SVG patency, and demonstrated no statistically significantly higher bleeding events compared to other antiplatelet regimens.
BACKGROUND: Aspirin (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), has not been well-established in all CABG patients. We performed a network meta-analysis (NMA) to compare the effects of various antiplatelet therapy regimens on saphenous vein graft (SVG) patency, all-cause mortality, and bleeding outcomes amongst adult patients following CABG.

METHODS AND RESULTS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC and grey literature sources (AHA, ACC, ESC and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. Screening, data extraction, risk of bias (ROB) and GRADE were performed in duplicate. The NMA was performed with R, the results reported as odds ratios, and the I2 value was reported for heterogeneity. We used the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. We included 41 RCTs comprising 14,014 patients. For reduction in SVG stenosis and obstruction at one-year, therapy with ASA and ticagrelor ranked first. Compared to ASA monotherapy, DAPT with ASA and ticagrelor statistically significantly reduced stenosis (odds ratio [OR] 0.41, 95% credible interval [CrI]: 0.25,0.70). For reduction in all-cause mortality at one-year, monotherapy with clopidogrel was ranked first. Compared to ASA only, clopidogrel statistically significantly reduced mortality (OR 2.0e-09, 95%CrI: 2.7e-26, 1.0). Meanwhile, DAPT with ASA and ticagrelor demonstrated a direction towards lower all-cause mortality at one-year (OR 0.38, 95%CrI: 0.013, 5.8) when compared to ASA monotherapy, but failed to reach statistical significance. For major bleeding events at one-year, placebo or no antiplatelet therapy ranked first. However, compared to standard of care (ASA monotherapy), DAPT with ASA and ticagrelor or ASA and clopidogrel was not associated with a statistically significant increase in bleeding. Heterogeneity for SVG stenosis, and bleeding was low (I2 ≤25%), and high for mortality (I2 >50%).

CONCLUSION: Our work is the largest and most comprehensive quantitative synthesis of RCT data regarding the use of antiplatelet therapy following coronary artery bypass grafting surgery. The network ranked ASA and ticagrelor first for SVG patency, and demonstrated no statistically significantly higher bleeding events compared to other antiplatelet regimens.
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