Abstract 12204: Optimal Antithrombotic Therapy After Coronary Artery Bypass Surgery: More is Not Better!
Background: ASA is indicated after CABG, and recent studies show clopidogrel also improves vein graft patency. However, patients treated with warfarin preoperatively pose a challenge, and may be at increased risk for bleeding. We assessed the hypothesis whether clopidogrel should be added to all post-CABG patients.
Methods: 414 consecutive patients undergoing CABG at a single urban center from January 1, 2008, to April 30, 2012 were enrolled. All were discharged on ASA 325 mg. Those already on clopidogrel and/or warfarin were continued. The choice to start clopidogrel (75 mg daily) was at the discretion of the cardiologist. Patients were followed up for at least 1 year. The primary endpoint included all-cause mortality, incidence of vein graft occlusion/ischemic stroke, readmission, and bleeding events based on GUSTO trial.
Results: Mean follow-up was 902.4 ± 390.7 days.
• Patients discharged with clopidogrel had lower all-cause mortality upon 1-year follow up, lower vein graft occlusion, and readmission.
• ASA-based therapy lowered all-cause mortality except those on all 3 drugs. This was consequent to severe bleeding in 2 patients who died from ICH.
• The risk of bleeding events was increased in those on clopidogrel plus ASA, and was highest in patients on all 3 drugs compared to ASA alone (table 2). There was no difference in the incidence of ischemic stroke across subgroups.
Conclusion: In conclusion, clopidogrel plus ASA is as effective as ASA alone in lowering all-cause mortality after CABG, and has significantly lower vein graft occlusion and readmission rate. However, there is slightly increased bleeding risk.
• Triple antithrombotic therapy has extremely high risk of fatal and nonfatal bleeding without any mortality, vein graft occlusion, and readmission benefits, and therefore should be avoided.
• In patients with high risk of thromboembolism in whom warfarin is indicated, adding ASA lowers all-cause mortality, but is associated with significantly more bleeding.
- © 2013 by American Heart Association, Inc.