Dual antiplatelet therapy after CABG: does ticagrelor plus aspirin improve graft patency enough to outweigh major bleeding? an updated systematic review and meta-analysis of 9,659 patients

Background Optimal antiplatelet therapy after coronary artery bypass grafting (CABG) remains uncertain. While aspirin remains the standard of care, intensified platelet inhibition with ticagrelor plus aspirin has been proposed to improve saphenous vein graft (SVG) patency. However, whether this benefit outweighs the increased risk of major bleeding and translates into improved clinical outcomes remains uncertain. Purpose To assess whether the graft patency benefit of ticagrelor plus aspirin after CABG outweighs the risk of major bleeding, and to evaluate its effects on mortality and ischaemic outcomes Methods PubMed and Embase were systematically searched from inception through December 30, 2025, for randomized and observational studies comparing ticagrelor-based DAPT versus aspirin monotherapy after CABG. Primary outcomes included major bleeding, all-cause mortality, cardiovascular mortality, and SVG occlusion at 1 year. Secondary outcomes were myocardial infarction, stroke, and repeat revascularization. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. Heterogeneity was assessed using the Chi-squared test and I² statistic. Prespecified subgroup analyses were performed according to study design. Results Five studies, including 9,659 patients (3,369 patients with ticagrelor and aspirin, and 6,290 with aspirin alone) were analyzed. DAPT with Ticagrelor and aspirin was associated with a lower risk of SVG occlusion (RR 0.63, 95% CI 0.47–0.85; p=0.002; I²=2%) but increased major bleeding risk (RR 1.69, 95% CI 1.06–2.72; p=0.03; I²=42%). No significant differences were observed for stroke, myocardial infarction, cardiovascular mortality and new revascularization. Conclusion After CABG, ticagrelor plus aspirin improves SVG patency but increases major bleeding compared with aspirin alone, without clear benefits in other clinical outcomes. These findings support selective use of ticagrelor-based DAPT in patients with a higher graft-failure risk profile and low bleeding risk, whereas aspirin alone may be favoured in patients with elevated bleeding risk.. Further adequately powered RTCs are needed to identify patient subgroups most likely to derive a net clinical benefit.