that if aspirin is not tolerated, clopidogrel is an acceptable alternative, but there is no strong evidence that clopidogrel is superior to aspirin postcoronary surgery.
REF. : Department of Cardiology, Stepping Hill Hospital, Stockport, Manchester, UK
↵* Corresponding author. Address: Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK. Tel.: +44-780-154-8122; fax: +44-161-276-8538 [email protected]
I would add if it was diffusely atheromatous coronary arteries seen intraoperatively, you might consider to give clopidogrel for 3 months postoperatively.
guidelines for revascularization (ACC/AHA 2011) mentions copidogrel after CABG as class IIa recommendation if Aspirin is not tolerated. but it doesnt say for how long should it be used.
Our current approach is to give clopidogrel for 12 months in conjunction with aspirin if thrombendarterectomy was performed and/or if there is diffuse coronary artery disease.
In fact, a study has recently been initiated by the German Heart Center in Munich which will compare Ticagrelor 90 mg bid plus ASA-placebo with Asprin 100 mg plus Ticagrelos-Placebo in a randomized, double-blind multicenter setup.
There is no clear evidence that dual antipletalate (clopidogrel and aspirin) is superior to aspirin only, unless aspirin is not tolerated or contraindicated, but if to be given as some studies suggested is to be for 3 months only and continue aspirin for life to prevent early graft blockage
Few RCT available and results are inconsistent.
Evidences from recent analysis of RCT after DES implantation suggest that prolonged Dual antoplatelet therapy can increase all cause mortality due to fatal bleeding.
I would not recommend DAPT after CABG longer than 9-12 months.
While there is no general consensus it depends on which target group we are treating:
Off pump CABG -6 to 12 months of DAPT( Aspirin + Clopidogrel) is probably adequate
If CABG was done in the setting of recent MI- then use it similar to PCI protocol- 6-12 months /as tolerated.Longer the better if no GI/ tolerance and platelet resistance issues.
Not sure in cases of Aspirin allergy or intolerance.....and again in cases of diffuse disease and after endarterectomy- 3-6 months perhaps.These are grey areas.
It depends. The patients who are suffering from angina pectoris and no obvious myocardial infarction prior to by-pass are advised to take aspirin and statin for life after CABG. It worths mentioning at we give fragmin 5000 ie from day 1, for 5 days after cardiac operations. If s/he can't tolerate aspirin, we order clopidogrel for life. If the patient is diagnosed myocardial infarction within one year before CABG, s/he continues lifelong aspirin, but clopidogrel or ticagrelor(brilique) is given one year from the day s/he had myocardial infarction. If Angina pectoris and no infarction then patient treated with PCI, depends on type of stent, clopidrogre or ticagrelor is orderet for 3-6 months and lifelong aspirin and statin. The patients who have cereberal infarction and have IHD, are advised to continue clopidogrel lifelong.
we do not use DAPT after CABG standard, all patients are treated with ASA 100mg once daily unless the coronaries were severely atherosclerotic or an endarterectomy had to be performed, in which cases we add clopidogrel for one year. Keep in mind the significant amount of non-responders to clopidogrel, however. Recently, studies are including patients to show that there could be a benefit in survival if patients that had been treated by ASA and ticagrelor before CABG are restarted on that dual therapy post CABG for a duration of one year, hereby improving graft patency (cfr PLATO trial). Longterm results are still awaited.
https://clinicaltrials.gov/ct2/show/NCT01373411
Aspirin is not tolered ? why ? Perhaps you could use a very low dosage of Aspirin without any digestive adverse effect (50mg / day). If you use Clopidogrel, itsnot indicated to follow this therapy for the rest of his life because of adverses effects, frequent and possibly severe. Personnaly I didn't use this therapy for more than 6 months after CABG.
We use DAPT for about one year in all patients having isolated multivessel CABG (obviously if they have not problems of intolerance/allergy) particularly if they are not extremely aged (< 85)
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