Author + information
- Christopher Kelly1,
- Joseph Sabik2,
- A. Pieter Kappetein3,
- William Brown4,
- Nicolas Noiseux5,
- Jose Pomar6,
- Yiran Zhang7,
- Patrick Serruys8 and
- Gregg Stone9
- 1Columbia University, New York, New York, United States
- 2Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, United States
- 3Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- 4Piedmont Heart Institute CardioThoracic Surgeons, Atlanta, Georgia, United States
- 5Montreal Heart Institute, Montreal, Quebec, Canada
- 6Hospital Clínic - University of Barcelona, Barcelona, Spain
- 7Cardiovascular Research Foundation, New York, New York, United States
- 8Imperial College, London, United Kingdom
- 9Cardiovascular Research Foundation, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
The role of P2Y12 inhibitors after CABG remains controversial, with some studies reporting improved graft patency and clinical outcomes, particularly after off-pump surgery.
In the EXCEL trial, 1905 pts with left main coronary artery disease (LMCAD) and low/intermediate SYNTAX scores were randomized to PCI (n=948) or CABG (n=957). We examined post-CABG outcomes based on DAPT use at discharge. The primary endpoint was a composite of death, stroke, or MI at 3 years. A secondary endpoint was symptomatic graft stenosis/occlusion.
CABG was performed in 923 of the 957 assigned pts. Of these, 593 (67%) survived to discharge and were prescribed aspirin alone, while 288 (33%) also received a P2Y12 inhibitor (98% clopidogrel). Pts discharged on DAPT were likelier to be in North America (53.1% vs 33.1%, p<0.0001), to be current smokers (25.8% vs 19.1%, p=0.02), and to have a history of CVA/TIA (10.4% vs 5.2%, p=0.004). There were no differences in the rates of ACS at presentation or of prior MI, PCI, or anemia. Pts on DAPT were likelier to have had off-pump CABG (41.0% vs 23.1%, p<0.0001) and less likely to have ≥2 arterial grafts (25.3% vs 34.1%, p=0.008) or BARC 2-5 bleeding during the index hospitalization (8.3% vs 13.0%, p=0.04). There were no significant differences in the primary endpoint, its components, graft stenosis/occlusion, or bleeding at 3 years (Table). By multivariable analysis, DAPT at discharge did not predict the primary outcome at 3 years (p= 0.77).
|3-year event rates||DAPT at discharge (n=288)||Aspirin only at discharge (n=593)||P value|
|Primary Endpoint (Death, Stroke, MI)*||13.7% (38)||13.8% (79)||0.92|
|Death*||3.5% (9)||4.9% (27)||0.35|
|MI*||9.2% (26)||7.8% (45)||0.42|
|Ischemia-Driven Revascularization*||8.3% (22)||6.7% (38)||0.48|
|Graft Stenosis or Occlusion*||5.9% (16)||5.5% (31)||0.83|
|BARC 2-5 bleeding**||10.4% (30)||14.7% (87)||0.08|
*Adjudicated events reported as KM estimates (n) and compared using log-rank test. **Non-adjudicated event reported as proportions (n) and compared using chi-squared test.
In the EXCEL trial, discharging pts with LMCAD on DAPT after CABG did not have a major effect on long-term adverse ischemic or bleeding events, including symptomatic graft occlusion.
CORONARY: Cardiac Surgery