Ticagrelor-based dual antiplatelet therapy versus aspirin monotherapy after CABG: a systematic review and meta-analysis of randomized controlled trials

Background Antiplatelet therapy after coronary artery bypass grafting (CABG) plays a central role in preventing graft thrombosis and reducing adverse cardiovascular events. Aspirin is universally recommended as the cornerstone of postoperative antiplatelet therapy; however, the incremental benefit of dual antiplatelet therapy (DAPT) with ticagrelor remains uncertain. While some trials have suggested potential improvements in graft patency, concerns persist regarding bleeding risk and the lack of consistent benefit on clinical outcomes. Purpose To systematically evaluate the efficacy and safety of ticagrelor-based DAPT following CABG in patients with acute coronary syndrome (ACS) or stable coronary artery disease (CAD). Methods We conducted a systematic search of Embase, MEDLINE, and Cochrane databases from inception to December 2025 to identify randomized controlled trials (RCTs) comparing ticagrelor plus aspirin versus aspirin monotherapy in patients undergoing CABG for ACS or stable CAD. Binary outcomes were pooled as risk ratios (RR) with 95% confidence intervals (CI) using a Mantel–Haenszel common-effect model, while continuous outcomes were summarized as mean differences (MD). Heterogeneity was assessed using Cochrane’s Q test and Higgins and Thompson’s I² statistic. All analyses were performed using R software (version 4.4.2). Results Following PRISMA guidelines, 2,573 records were screened, and 4 RCTs comprising 3,101 patients were included, of whom 50.1% were allocated to ticagrelor-based DAPT. Using a common-effect model, ticagrelor-based DAPT was associated with a significantly higher risk of all-cause mortality over a follow-up ranging from 1 to 5 years compared with aspirin monotherapy (RR 2.15; 95% CI 1.17–3.94; p = 0.013), with moderate heterogeneity across studies (I² < 50%). At 1 year, DAPT was also associated with significantly increased risks of major bleeding (RR 2.10; 95% CI 1.37–3.21; p < 0.001) and minor bleeding (RR 2.92; 95% CI 1.72–4.96; p < 0.001), both with moderate heterogeneity (I² < 50%). Conclusion In patients undergoing CABG, ticagrelor-based dual antiplatelet therapy was associated with higher risks of all-cause mortality and bleeding. These findings highlight important safety concerns regarding the routine use of ticagrelor-based DAPT after CABG and support a cautious, individualized approach to postoperative antiplatelet management.Major and minor bleending after 1 year.All-cause mortality after 1-5 years.