Antiplatelet Therapy after Coronary Artery Bypass Surgery: An Updated Network Meta-analysis of Randomized Clinical Trials

Background:
Recently, several trials have suggested that adding a p2y12 inhibitor (p2y12i) to aspirin (ASA) therapy can improve outcomes after CABG. However, it is not clear which P2Y12i is best and if ASA+p2y12i is more effective than a p2y12i alone. In recent months, results of the TICAB trial (the largest trial in this field) have been reported. Therefore, we performed an updated network meta-analysis of the clinical trials.

Methods:
Scientific databases were searched, and a Bayesian network meta-analysis was performed using a random effects model. Because follow-up durations varied across trials, standardized event rates were converted to events/per 100,000 patient-days.

Results:
Data from 12 trials including 4964 patients were analyzed. Both ASA+ Clopidogrel and ASA+clopidogrel were associated with significantly lower MACE rates compared to ASA or ticagrelor alone, but no difference between ASA+ clopidogrel and ASA+ticagrelor was found (Figure). Additionally, ASA+ticagrelor was associated with a significantly higher rate of major bleeding compared to ASA alone and ASA+ clopidogrel (Figure). Conversely, ASA+ clopidogrel was associated with a numerically higher risk of major bleeding compared to ASA alone, but the difference does not reach statistical significance. Finally, the rate of SVG occlusion was significantly lower for ASA+ clopidogrel compared to ASA alone, but it did not differ between ASA+ clopidogrel and ASA+ticagrelor (Figure).

Conclusions:
After CABG, patients given ASA+ clopidogrel l as antiplatelet therapy seem to achieve the best net efficacy and safety profiles.