Two-drug strategy offers both benefits and risks after coronary artery bypass surgery

A new analysis shows that a combination of two antiplatelet drugs may benefit people after the most common type of heart surgery, while increasing the risk of potentially dangerous bleeding. This double-edged finding by Weill Cornell Medication and NewYork-Presbyterian investigators suggests that physicians should carefully weigh the use of these medications after this procedure.

In an analysis published August 9 in JAMA, a team led by Dr. Mario Gaudino, a coronary bypass surgeon, examined data from 1 668 transplants in which the surgeons use a piece of vein taken from the leg to bypass blocked coronary arteries. Sometimes, however, blood clots form in the grafted vein, obstructing blood flow. Typically, patients are given aspirin however, some evidence suggests that aspirin plus a prescription antiplatelet agent, such as ticagrelor, may more effectively prevent this clotting.

“We have found that, yes, this dual therapy considerably reduces the risk of graft failure. However, for the first time, we have shown that this approach also carries a life-threatening risk of clinically significant bleeding,” said Dr. Gaudino, the Stephen and Suzanne Weiss Professor of Cardiothoracic Surgery at Weill Cornell Medicine and Cardiothoracic Surgeon at New York- Presbyterian/Weill Cornell Health Care Centre. “So the benefit comes at a price.”

Taken together, these results indicate that physicians should base their decisions on the individual circumstances of patients and avoid using this approach for those who have situations that put them at risk of bleeding, he said.

Every year, approximately 300 000 patients undergo coronary bypass surgery to treat narrowed or clogged arteries that deprive the heart muscle of oxygen-rich blood. In over 90% of these procedures, surgeons remove a graft from one of the patient’s saphenous veins, which carries blood to the inside of the legs. . However, within a year, up to a quarter of these grafts become clogged.

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 came to conflicting conclusions. The team, including first author Dr. Sigrid Sandner, a master’s student in clinical epidemiology at the Weill Cornell Graduate University of Professional medical Sciences, contacted researchers on four of these trials to gain access to their raw data. . The team then compiled this data, creating a much larger study capable of generating stronger conclusions.

They found a failure rate of approximately 11% in patients who received a combination of aspirin and ticagrelor, while blockages occurred in 20% of transplants when patients received aspirin only. However, compared to aspirin alone, DAPT caused more bleeding events which, although generally not life-threatening, required medical attention.

In these previous trials, people received DAPT for a full year. However, most graft failures occur within the first few months after surgery. Next, Dr. Gaudino, who is also director of the Joint Clinical Trials Place of work at Weill Cornell Drugs and NewYork-Presbyterian, hopes to test aspirin and ticagrelor over one to three months to see if a shortened treatment offers the same benefit with less risk of bleeding.

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