Ebrahimi Ramin, Gupta Sandeep, Carr Brendan M, Bishawi Muath, Bakaeen Faisal G, Almassi G Hossein, Collins Joseph, Grover Frederick L, Quin Jacquelyn A, Wagner Todd H, Shroyer A Laurie W, Hattler Brack
Department of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, University of California Los Angeles, Los Angeles, California.
Research Service, Northport VA Medical Center, Northport, New York.
Am J Cardiol. 2018 Mar 15;121(6):709-714. doi: 10.1016/j.amjcard.2017.12.010. Epub 2018 Jan 2.
Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p <0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p <0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.
冠状动脉旁路移植术（CABG）后最佳抗血小板治疗仍存在争议。本研究评估了阿司匹林和氯吡格雷双联抗血小板治疗（DAPT）与单用阿司匹林抗血小板治疗（ASA）对CABG术后临床结局和成本的作用。在退伍军人事务部随机搭桥/非搭桥（ROOBY）试验中，从本研究第2年开始前瞻性收集CABG术后氯吡格雷的使用情况，纳入2203例CABG术后接受阿司匹林治疗的ROOBY原始患者中的1525例。CABG术后，外科医生酌情给予DAPT或ASA治疗。比较了这两种策略的ROOBY试验主要30天复合结局（死亡率或围手术期发病率）、1年复合结局（全因死亡、再次血运重建或非致命性心肌梗死）及成本。在1525例受试者中，511例接受DAPT，1014例接受ASA。与ASA受试者相比，DAPT受试者术前左心室射血分数≥45%的比例较低（78.8%对85.7%，p<0.001），体外循环CABG比例较低（36.6%对57.1%，p=0.001），内镜下取静脉比例较低（30.0%对42.8%，p<0.001）。ASA患者更可能更早给予阿司匹林，且接受325 mg而非81 mg剂量。与ASA患者相比，DAPT患者的30天复合结局率显著更低（3.3%对7.1%，p=0.003），但两组的1年复合结局相同（12.0%对12.0%，p=1.0）。1年时，两组之间无成本差异。倾向分析未显著改变结果。总之，DAPT似乎安全，与单用阿司匹林相比30天不良结局更少，且1年结局或成本无差异。
