Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
Can J Cardiol. 2019 Aug;35(8):1030-1038. doi: 10.1016/j.cjca.2019.06.003. Epub 2019 Jun 11.
This review was undertaken to summarize and discuss the current evidence around antiplatelet therapy and coronary artery bypass grafting (CABG). Aspirin (ASA) monotherapy remains the standard of care among patients before and after CABG. The role of more intense antiplatelet therapy-specifically, P2Y12 inhibitors-in improving clinical outcomes and graft patency is becoming increasingly apparent. As such, we provide an overview of a variety of antiplatelet regimens. The review discusses the evidence around preoperative management of antiplatelet therapies, with a particular focus on timing of cessation. It also evaluates the current literature to elucidate the best antiplatelet therapy regimen after CABG, focusing on acute coronary syndrome (ACS). Whenever possible, data are presented from randomized controlled trials (RCTs) and meta-analyses. Although guidelines recommend use of dual antiplatelet therapy (DAPT) after CABG for patients with ACS, available evidence is limited to small RCTs, and meta-analyses are of substudies of larger RCTs. There is also considerable heterogeneity in patient population of these studies; a significant number of patients underwent off-pump CABG (OPCAB) in trials that demonstrate graft-patency benefit with DAPT. With this limited evidence, DAPT remains underused in the CABG population, even among patients presenting after ACS.
这篇综述旨在总结和讨论目前关于抗血小板治疗和冠状动脉旁路移植术（CABG）的证据。阿司匹林（ASA）单药治疗仍然是 CABG 前后患者的标准治疗方法。更强化的抗血小板治疗，特别是 P2Y12 抑制剂，在改善临床结局和移植物通畅性方面的作用越来越明显。因此，我们提供了各种抗血小板方案的概述。本综述讨论了术前抗血小板治疗管理的证据，特别关注停药时间。它还评估了目前的文献，以阐明 CABG 后最佳的抗血小板治疗方案，重点是急性冠状动脉综合征（ACS）。只要有可能，就会从随机对照试验（RCT）和荟萃分析中呈现数据。尽管指南建议对 ACS 患者在 CABG 后使用双联抗血小板治疗（DAPT），但可用证据仅限于小型 RCT，荟萃分析是更大 RCT 的亚研究。这些研究的患者人群也存在相当大的异质性；在证明 DAPT 对移植物通畅有益的试验中，有相当数量的患者接受了非体外循环冠状动脉旁路移植术（OPCAB）。鉴于这一有限的证据，即使是 ACS 后就诊的患者，DAPT 在 CABG 人群中的使用仍然不足。
