Kevin Malloy Highlights ESC 2025 Data: TACSI and TOP-CABG Trials Redefine Post-CABG Antiplatelet Therapy
Kevin Malloy, Clinical Pharmacy Specialist at Cleveland Clinic, posted on LinkedIn:
”Post-CABG: to DAPT or not to DAPT?
AHA 2021 Coronary Revascularization Guidelines:
“In selected patients undergoing CABG, DAPT (ticagrelor/clopidogrel + aspirin) for 1 yr may be reasonable to improve vein graft patency compared with aspirin alone (class 2b, LOE B-R)”
Well two hot off the press (conference) trials from ESC 2025 are reshaping our post-CABG antiplatelet strategy:
- Population: n=2,201 *ACS* post-CABG
- Intervention: ticagrelor + aspirin (12 months, open-label)
- Comparison: aspirin *mono*therapy (yes, aspirin monotherapy post-ACS)
- Outcome: *at 1 yr* (10 yr follow-up study ongoing):
– Thrombotic (MI, stroke, revasc, death): 4.8% vs. 4.6% → HR 1.06 (95% CI: 0.72–1.56)
– Major bleeding: 4.9% vs. 2.0% → HR 2.50 (95% CI: 1.52–4.11)
But what about the GRAFT?
TOP-CABG Trial
(not yet published)
- Population: CABG (ACS and SIHD) with 1+ saphenous vein graft, SVG (these guys are more prone to thrombosis)
- Intervention: De-escalated DAPT (“De-DAPT”), ticagrelor + aspirin → *3 month*→ aspirin monotherapy
- Comparison: ticagrelor + aspirin (12 months)
- Outcome:
– SVG occlusion (1 yr post-CABG, via coronary CT/A) 10.79% in De-DAPT vs 11.19% in DAPT (difference −0.31%; 95% CI: −3.13-2.52, non-inferiority margin +3.5% met ✔️)
– Bleeding (BARC ≥2): 8.3% vs. 13.2% (HR 0.62; 95% CI: 0.48 to 0.81)
Take-home pearls: Post-CABG Antiplatelet Therapy:
– Aspirin monotherapy is appropriate for most patients after CABG — especially those with SIHD or elevated bleeding risk.
– Even in ACS or SVG grafting, pumping the brakes on DAPT by 3 months is probably the right choice — extended use rarely adds benefit and increases bleeding risk.
Always individualize:
– Assess ischemic vs bleeding risk (PRECISE-DAPT score)
– Account for prior bleeding, GI risk, and consider PPI prophylaxis
– Factor in graft type, clinical context, and patient preferences.”
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