A new analysis shows that a combination of two antiplatelet drugs may benefit patients after the most common type of heart surgery -; while increasing the risk of potentially dangerous bleeding. This double-edged finding by researchers at Weill Cornell Medicine and NewYork-Presbyterian suggests that doctors should carefully weigh the use of these medications after this procedure.
In an analysis reported Aug. 9 in JAMA, a team led by Dr. Mario Gaudino, a coronary artery bypass surgeon, examined data from 1,668 grafts in which surgeons use a piece of vein taken from the leg to bypass arteries blocked coronary arteries. Sometimes, however, blood clots form inside the grafted vein, obstructing blood flow. Patients are usually given aspirin; however, some evidence suggests that aspirin along with a strong prescription antiplatelet agent, such as one called ticagrelor, may more effectively prevent this clotting.
We found that, yes, this dual therapy significantly reduces the risk of grafts failing. However, for the first time, we have shown that this approach also carries a significant risk of clinically significant bleeding. So benefit comes at a price.”
Dr. Mario Gaudino, Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine and cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center
Taken together, these results indicate that doctors should base their decisions on individual patients’ circumstances and avoid using this approach for those with conditions that put them at risk of bleeding, he said.
Each year, approximately 300,000 patients undergo coronary artery bypass grafting to treat narrowed or blocked arteries that deprive the heart muscle of oxygen-rich blood. In more than 90 percent of these procedures, surgeons take a graft from one of the patient’s saphenous veins, which carry blood down the inside of the legs. However, within a year, up to a quarter of these grafts become blocked.
Some studies have examined the benefit of giving patients both aspirin and ticagrelor, an approach known as dual antiplatelet therapy (DAPT). However, these studies were small and reached conflicting conclusions. The team, which includes first author Dr. Sigrid Sandner, a master’s student in clinical epidemiology at the Weill Cornell Graduate School of Medical Sciences, contacted investigators from four such trials to gain access to their data in dirty. The team then compiled this data, effectively creating a much larger study capable of generating stronger conclusions.
They found a failure rate of about 11 percent in patients who received a combination of aspirin and ticagrelor, while blockages occurred in 20 percent of grafts when patients received aspirin alone. However, compared with aspirin alone, DAPT resulted in more bleeding events that, although generally not life-threatening, required medical attention.
In these earlier trials, patients received DAPT for a full year. However, most graft failure occurs in the first few months after surgery. Next, Dr. Gaudino, who is also director of the Joint Clinical Trials Office at Weill Cornell Medicine and NewYork-Presbyterian, hopes to try aspirin and ticagrelor for one to three months to see if a reduced course offers the same benefit with less risk of suffering. bloody
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Journal reference:
Sandner, S., et al. (2022) Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery. JAMA. doi.org/10.1001/jama.2022.11966.