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Canadian Journal of Cardiology

Antiplatelet Therapy and Coronary Artery Bypass Grafting: Analysis of Current Evidence With a Focus on Acute Coronary Syndrome

      Abstract

      This review was undertaken to summarize and discuss the current evidence around antiplatelet therapy and coronary artery bypass grafting (CABG). Aspirin (ASA) monotherapy remains the standard of care among patients before and after CABG. The role of more intense antiplatelet therapy—specifically, P2Y12 inhibitors—in improving clinical outcomes and graft patency is becoming increasingly apparent. As such, we provide an overview of a variety of antiplatelet regimens. The review discusses the evidence around preoperative management of antiplatelet therapies, with a particular focus on timing of cessation. It also evaluates the current literature to elucidate the best antiplatelet therapy regimen after CABG, focusing on acute coronary syndrome (ACS). Whenever possible, data are presented from randomized controlled trials (RCTs) and meta-analyses. Although guidelines recommend use of dual antiplatelet therapy (DAPT) after CABG for patients with ACS, available evidence is limited to small RCTs, and meta-analyses are of substudies of larger RCTs. There is also considerable heterogeneity in patient population of these studies; a significant number of patients underwent off-pump CABG (OPCAB) in trials that demonstrate graft-patency benefit with DAPT. With this limited evidence, DAPT remains underused in the CABG population, even among patients presenting after ACS.

      Résumé

      La présente synthèse vise à résumer et à expliquer les données probantes actuelles concernant le traitement antiplaquettaire et le pontage aortocoronarien (PAC). La monothérapie par l’acide acétylsalicylique demeure le traitement de référence des patients avant et après un PAC. Le rôle d’un traitement antiplaquettaire plus intense (particulièrement par des inhibiteurs de la P2Y12) dans l’amélioration des résultats cliniques et de la perméabilité du greffon est de mieux en mieux connu. C’est pourquoi nous faisons également un survol de divers traitements antiplaquettaires. Notre synthèse présente les données probantes concernant la prise en charge périopératoire de traitements antiplaquettaires, en accordant une attention particulière au moment où ces traitements sont arrêtés. Nous évaluons également la littérature actuelle afin de trouver le meilleur traitement antiplaquettaire après un PAC, en mettant l’accent sur la présence d’un syndrome coronarien aigu (SCA). Dans la mesure du possible, les données présentées proviennent d’essais comparatifs avec répartition aléatoire (ECR) et de méta-analyses. Bien que les lignes directrices recommandent l’utilisation d’une bithérapie antiplaquettaire après un PAC chez les patients présentant un SCA, les données probantes proviennent uniquement d’ECR de petite envergure, tandis que les méta-analyses portent sur des sous-études d’ECR de plus grande envergure. La population de patients de ces études est très homogène; un nombre important de patients ont subi un PAC sans pompe dans le cadre d’études visant à démontrer les bienfaits de la bithérapie antiplaquettaire sur la perméabilité du greffon. La quantité de données probantes sur la bithérapie antiplaquettaire étant limitée, ce traitement demeure sous-utilisé chez les patients subissant un PAC, même ceux qui présentent un SCA.
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