Author + information
- Sean van Diepen, MD, MSc∗ (, )
- Valentin Fuster, MD, PhD and
- Michael E. Farkouh, MD, MSc
- ↵∗Divisions of Critical Care and Cardiology, University of Alberta T6G 2B7, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440 11 Street, Edmonton, Alberta, Canada
We thank Drs. Mori and Geirsson for their interest in our FREEDOM (Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease) study secondary analysis (1) examining aspirin monotherapy versus dual antiplatelet therapy (DAPT) in diabetic patients with multivessel coronary artery bypass grafting (CABG). We concur with the authors that the postulated benefits of DAPT after CABG include stabilization of the culprit lesion and preservation of both coronary stent and vein graft patency. In addition, DAPT treatment can theoretically: 1) reduce the risk of acute coronary syndrome (ACS) recidivism in nonculprit arteries irrespective of bypass grafting; 2) augment platelet inhibition in aspirin nonresponders; 3) reduce the risks of associated noncoronary conditions (e.g., stroke in patients not receiving anticoagulation for atrial fibrillation); and 4) mediate improved outcomes through nonplatelet receptor interactions (e.g., decreased infarct size via ticagrelor erythrocyte adenosine reuptake inhibition) (2–4).
However, as the authors have astutely highlighted, the evidence supporting routine DAPT post-CABG for the prevention of clinical events is based primarily on nonrandomized evidence with substantial inherent limitations, and the small randomized studies published to date have only demonstrated improved graft patency (5). Nonetheless, some clinical practice guidelines recommend 1 year of DAPT for ACS after CABG, thus we felt it was imperative to report results stratified by ACS and stable coronary artery disease.
Given the substantial clinical efficacy and safety uncertainty of DAPT for on-pump CABG, we believe a large randomized controlled trial adequately powered for mortality, graft patency, and safety outcomes should be a research priority for the cardiovascular community.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Deepak L. Bhatt, MD, MPH, served as Guest Editor-in-Chief for this paper; and Faisal Bakaeen, MD, served as Guest Editor for this paper.
- 2017 American College of Cardiology Foundation
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