Weekly Journal Scan: Rethinking dual antiplatelet therapy after coronary artery bypass grafting for acute coronary syndromes

This comment refers to ‘Ticagrelor and Aspirin or Aspirin Alone after Coronary Surgery for Acute Coronary Syndrome’ which was published in the New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2508026. Aspirin remains the cornerstone of antiplatelet therapy after CABG, aimed at reducing graft occlusion and ischaemic events.2 Current guidelines recommend early initiation, ideally within 6 h post-surgery, followed by lifelong continuation as the standard of care.2,3 The value of adding a P2Y12 inhibitor to aspirin after CABG is far less clear. While well established for patients undergoing percutaneous coronary intervention (PCI) and ACS, evidence in the surgical setting is limited. Small randomized studies and observational analyses have suggested that DAPT may improve saphenous vein graft patency, a surrogate endpoint, but this potential benefit was consistently offset by a higher risk of bleeding.4,5 These findings highlight the need to carefully balance ischaemic and bleeding risks, as both are independently linked to mortality.6 In the absence of large, dedicated randomized trials, current recommendations for DAPT after CABG are largely extrapolated from PCI studies and subgroup analyses of ACS trials.7 Indeed, in pivotal ACS trials such as PLATO and TRITON-TIMI 38, ticagrelor or prasugrel plus aspirin reduced post-CABG mortality compared to clopidogrel, though prasugrel was associated with greater postoperative bleeding.8,9 Real-world data remain conflicting. A large Korean registry reported that DAPT reduced CV death and MI in patients with ACS undergoing CABG,10 whereas the SWEDEHEART registry showed no reduction in ischaemic events and a significant increase in major bleeding with DAPT.11 These discrepancies underscore the uncertainty surrounding routine use of DAPT after CABG. Reflecting this uncertainty, current guidelines recommend 6–12 months of DAPT after CABG performed in the context of ACS, preferably with ticagrelor or prasugrel, provided bleeding risk is not high.2,3