Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America.
Division of Cardiology, Department of Medicine, University of Miami-Jackson Memorial Hospital, Miami, FL, United States of America.
Int J Cardiol. 2018 Oct 15;269:80-88. doi: 10.1016/j.ijcard.2018.07.083. Epub 2018 Jul 19.
The potential benefit and risks of dual antiplatelet therapy (DAPT) over single antiplatelet therapy (SAPT) in patients who undergo coronary artery bypass graft surgery (CABG) is controversial.
We performed a systematic review and meta-analysis of observational and randomized clinical trial (RCT) data comparing DAPT to SAPT following urgent or elective CABG. Subanalyses were performed restricted to: a) RCTs; b) stable ischemic heart disease (SIHD); c) extended duration DAPT (≥6 months); and d) follow-up ≥2 years.
Twenty-two studies comprising 20,315 patients undergoing CABG were included. Of the participants studied, 7481 (37%) received postoperative DAPT and 12,834 (63%) received SAPT. Overall, DAPT was associated with a lower cardiovascular (CV) mortality (OR 0.67; p = 0.02) and a trend towards lower all-cause mortality (OR 0.78; p = 0.08). There were no differences in rates of myocardial infarction or stroke. Subanalyses in RCTs, SIHD, and prolonged follow-up failed to demonstrate improvement in these outcomes with DAPT. However, in studies with extended duration DAPT, stroke was significantly reduced in the DAPT group (OR 0.47; p = 0.04). Saphenous vein graft (SVG) occlusion up to 1 year after CABG was significantly lower with DAPT overall (OR 0.64; p < 0.01) and in the RCT subanalysis (OR 0.58; p < 0.01). Major bleeding was significantly higher with DAPT (OR 1.31; p = 0.03).
While DAPT has been associated with lower CV mortality in observational samples undergoing CABG, such findings were not replicated in RCTs. Lower rates of SVG occlusion with DAPT are offset by a higher rate of major bleeding.
在接受冠状动脉旁路移植术（CABG）的患者中，双联抗血小板治疗（DAPT）相对于单药抗血小板治疗（SAPT）的潜在益处和风险存在争议。
我们对比较 CABG 后紧急或择期行 DAPT 与 SAPT 的观察性研究和随机临床试验（RCT）数据进行了系统评价和荟萃分析。亚分析仅限于：a）RCT；b）稳定型缺血性心脏病（SIHD）；c）延长 DAPT 时间（≥6 个月）；和 d）随访时间≥2 年。
共纳入 22 项研究，包括 20315 例行 CABG 的患者。在研究的参与者中，7481 例（37%）接受术后 DAPT，12834 例（63%）接受 SAPT。总体而言，DAPT 与心血管（CV）死亡率降低相关（OR 0.67；p=0.02），全因死亡率降低趋势（OR 0.78；p=0.08）。心肌梗死或卒中等发生率无差异。在 RCT、SIHD 和延长随访的亚分析中，DAPT 未能改善这些结局。然而，在 DAPT 持续时间延长的研究中，DAPT 组卒中发生率显著降低（OR 0.47；p=0.04）。CABG 后 1 年内，DAPT 组的隐静脉桥（SVG）闭塞显著降低（OR 0.64；p<0.01），在 RCT 亚分析中也有显著降低（OR 0.58；p<0.01）。DAPT 组大出血发生率显著升高（OR 1.31；p=0.03）。
尽管 DAPT 与接受 CABG 的观察性样本中 CV 死亡率降低相关，但 RCT 中并未复制这些发现。DAPT 可降低 SVG 闭塞率，但大出血发生率更高。
