Antiplatelet Therapy and Coronary Artery Bypass Grafting: Analysis of current evidence with a focus on acute coronary syndrome

Abstract This review was undertaken to summarize and discuss the current evidence around antiplatelet therapy and coronary artery bypass grafting (CABG). Aspirin (ASA) monotherapy remains the standard of care amongst patients before and after CABG. The role of more intense antiplatelet therapy, specifically P2Y12 inhibitors, in improving clinical outcomes and graft patency is becoming increasingly apparent. As such, we provide an overview of a variety of antiplatelet regimens. The review discusses the evidence around pre-operative management of antiplatelet therapies, with a particular focus on timing of cessation. It also evaluates the current literature to elucidate the best antiplatelet therapy regimen after CABG, focusing on acute coronary syndrome (ACS). Whenever possible, data is presented from randomized controlled trials (RCTs) and meta-analyses. While guidelines recommend use of dual antiplatelet therapy (DAPT) after CABG amongst ACS patients, available evidence is limited to small RCTs and meta-analyses are of sub-studies of larger RCTs. There is also considerable heterogeneity in patient population of these studies; a significant number of patients underwent off-pump CABG (OPCAB) in trials that demonstrate graft patency benefit with DAPT. With this limited evidence, DAPT remains underutilized in the CABG population, even amongst patients presenting after an ACS.