Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden.
Department of Medicine, South Älvsborg Hospital, Borås, Sweden.
JAMA Netw Open. 2021 Aug 2;4(8):e2122597. doi: 10.1001/jamanetworkopen.2021.22597.
Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.
To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.
Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.
Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.
A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results.
In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
指南建议对急性冠脉综合征（ACS）患者在冠状动脉旁路移植术后（CABG）进行双联抗血小板治疗（DAPT）。然而，这些建议的证据是薄弱的。
比较 ACS 患者 CABG 术后使用阿司匹林（ASA）和替格瑞洛或单用 ASA 治疗的中期结局。
设计、设置和参与者：这项队列研究使用了瑞典患者多个国家登记处的合并数据，这些患者被诊断为 ACS，随后接受了 CABG。所有纳入的患者均在 2012 年至 2017 年期间在瑞典接受了单纯 CABG，ACS 诊断在手术前不到 6 周，出院后存活 14 天，并在术后接受 ASA 联合替格瑞洛或 ASA 单药治疗。主要分析采用多变量 Cox 回归模型，同时进行倾向评分匹配模型作为敏感性分析。数据于 2020 年 5 月至 9 月进行分析。
术后抗血小板治疗，定义为使用 ASA 和替格瑞洛或仅使用 ASA 的处方。
主要不良心血管事件（MACE），定义为所有原因死亡率、心肌梗死和卒中和大出血，在 12 个月和随访结束时。
共纳入 6558 例患者（5281 例[80.5%]为男性；手术时平均[SD]年龄为 67.6[9.3]岁）；1813 例（27.6%）接受 ASA 联合替格瑞洛治疗，4745 例（72.4%）接受 ASA 单药治疗。ASA 联合替格瑞洛组的 MACE 发生率为 3.0/100 人年（95%CI，2.5-3.6/100 人年），ASA 组为 3.8/100 人年（95%CI，3.5-4.1/100 人年）。调整后，ASA 联合替格瑞洛与 ASA 单药治疗的 MACE 风险无显著差异，无论是在最初的 12 个月（调整后的危险比[HR]，0.84；95%CI，0.58-1.21；P = .34）还是总随访期间（调整后的 HR，0.89；95%CI，0.71-1.11；P = .29）。ASA 联合替格瑞洛与 12 个月内大出血风险显著增加相关（调整后的 HR，1.90；95%CI，1.16-3.13；P = .011）。敏感性分析证实了这些结果。
在 CABG 后存活 2 周的 ACS 患者中，ASA 联合替格瑞洛与仅接受 ASA 治疗的患者相比，死亡或缺血性事件的风险无显著差异，但接受 ASA 联合替格瑞洛治疗的患者大出血风险更高。需要进行充分的、有说服力的、前瞻性随机临床试验来比较 CABG 术后不同的抗血小板治疗策略。
