Safety and Efficacy of Ticagrelor with Aspirin DAPT vs. Aspirin Alone in Patients Undergoing CABG Following ACS: A Systematic Review and Meta-Analysis

BACKGROUND: It remains uncertain whether Dual Antiplatelet Therapy (DAPT) or aspirin alone is better for patients following Coronary Artery Bypass Grafting (CABG) post-Acute Coronary Syndrome (ACS). Currently available Systematic Reviews and Meta-Analyses (SRMA) are limited to the analysis of different combinations of DAPT across various clinical conditions of cardiovascular disease and are not restricted to CABG post-ACS. This SRMA aimed to evaluate the safety and efficacy of Ticagrelor with Aspirin (TA) versus aspirin alone in patients who underwent CABG following ACS. METHODS: Electronic databases were searched for studies involving patients who underwent CABG after ACS and received TA in the intervention arm versus aspirin in the control arm. The primary outcomes were death and major bleeding. The secondary outcomes were Composite Cardiovascular Outcomes (CCO), Myocardial Infarction (MI), stroke, saphenous vein graft patency, revascularization, and side effects. RESULTS: Data from five studies (4 RCTs and one cohort study; 9,659 patients) were analysed. The risk of death [OR 1.18 (95% CI 0.60-2.28); P =0.63; I²=46%] and major bleeding [OR 1.65 (95% CI 0.95-2.86); P =0.07; I²=44%] was numerically higher with TA than with aspirin alone, although these differences were not statistically significant. Composite cardiovascular outcomes [OR 0.96 (95% CI 0.74-1.24); P=0.74; I²=0%], myocardial infarction [OR 0.99 (95% CI 0.67- 1.46); P =0.94; I²=0%], stroke [OR 0.60 (95% CI 0.33-1.08); P =0.09; I²=0%], saphenous vein graft patency [OR 1.75 (95% CI 0.93-3.27); P =0.08; I²=75%], and revascularisation [OR 1.21 (95% CI 0.46-3.15); P =0.70; I²=49%] were similar between the two groups. DISCUSSION: These findings suggest that the theoretical advantage of intensified platelet inhibition with ticagrelor-based DAPT does not translate into improved clinical outcomes in patients undergoing CABG after ACS. The pathophysiology of graft failure, which is often driven by technical factors and progressive atherosclerosis rather than platelet-mediated thrombosis alone, may partly explain the absence of additional benefit from potent dual antiplatelet therapy. At the same time, the observed numerical increase in bleeding events highlights the potential trade-off associated with more aggressive platelet inhibition in the postoperative setting. CONCLUSION: In patients undergoing CABG following ACS, ticagrelor-aspirin DAPT does not confer significant improvement in ischemic outcomes compared with aspirin monotherapy and may increase bleeding risk. Aspirin alone appears to provide comparable protection, supporting its continued role as the cornerstone of antiplatelet therapy after surgical revascularization. Nevertheless, antiplatelet therapy after CABG should be individualised according to each patient's ischaemic/thrombotic and bleeding risk rather than applied uniformly.