Effectiveness and Safety of Dual Anti-platelet Therapy after Coronary Artery Bypass Grafting: A Meta-Analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 LIJun-hong , AIKEREMU ,  MuLa-Ti , ZHANGMing-ming , YILIHAMU , AIKEBAIER

Department of Cardiac Surgery Division One, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

MuLa-Ti, Email: muratvkili@hotmail.com

Keywords：

Coronary artery bypass grafting(CABG); Aspirin; Clopidogrel; Dual anti-platelet therapy; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20140159

Video：

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Objective To systematically review the effectiveness and safety of aspirin-clopidogrel combined anti-platelet therapy after coronary artery bypass grafting (CABG). Methods Databases including The Cochrane Library (Issue 2, 2013), PubMed, EMbase, CBM, CNKI, WanFang Data and VIP were searched electronically from their inception to September 2013 for randomized controlled trials (RCTs) about aspirin-clopidogrel combined anti-platelet therapy after CABG. Two reviewers selected literature independently according to the inclusion and exclusion criteria. After data extraction and methological quality assessment of the included studies, meta-analysis was performed using RevMan 5.2 software. Results A total of six RCTs involving 901 patients were included, of which 449 cases were in the aspirin-clopidogrel group (A+C) and 452 cases were in the aspirin with or without placebo group (A+P). The results of meta-analysis showed that: compared with A+P, A+C significantly reduced occlusion rates of the saphenous vein graft (RR=0.59, 95% CI 0.43 to 0.80, P=0.000 6). But no significant difference was found between the two groups in occlusion rates of the left internal mammary artery graft (RR=0.88, 95% CI 0.35 to 2.18, P=0.78), radial artery graft (RR=0.43, 95% CI 0.13 to 1.46, P=0.18), pleural fluid drainage volume (MD=-1.68, 95%CI-48.69 to 45.32, P=0.94), incidence of major bleeding events (RR=1.20, 95% CI 0.39 to 1.65, P=0.75), major cardiovascular events (OR=0.81, 95% CI 0.38 to 1.72, P=0.58), and mortality within 30 days (RR=0.64, 95% CI 0.17 to 2.44, P=0.52). Conclusion In reducing occlusion rates of the saphenous vein graft, the A+C group is more effective than the A+P group. Due to the limited quantity and quality of the included studies, the above conclusion still needs to be verified by carrying out more high-quality RCTs.

Citation： LIJun-hong, AIKEREMU, MuLa-Ti, ZHANGMing-ming, YILIHAMU, AIKEBAIER. Effectiveness and Safety of Dual Anti-platelet Therapy after Coronary Artery Bypass Grafting: A Meta-Analysis. Chinese Journal of Evidence-Based Medicine, 2014, 14(8): 958-965. doi: 10.7507/1672-2531.20140159 Copy

1.	Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Thorac Cardiovasc Surg, 2012, 143(1): 4-34.
2.	Stein PD, Schunemann HJ, Dalen JE, et al. Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004, 126(3 Suppl): 600S-608S.
3.	Gurbuz AT, Zia AA, Vuran AC, et al. Postoperative clopidogrel improves mid-term outcome after off-pump coronary artery bypass graft surgery: a prospective study. Eur J Cardiothorac Surg, 2006, 29(2): 190-195.
4.	Kulik A, Le May M, Wells GA, et al. The clopidogrel after surgery for coronary artery disease (CASCADE) randomized controlled trial: clopidgorel and aspirin versus aspirin alone after coronary bypass surgery. Curr Control Trials Cardiovasc Med, 2005, 11(6): 15.
5.	Patel JH, Stoner JA, Owora A, et al. Evidence for using clopidogrel alone or in addition to aspirin in post coronary artery bypass surgery patients. Am J Cardiol, 2009, 103(12): 1687-1693.
6.	高歌, 胡盛寿, 郑哲, 等.双联抗血小板治疗对冠状动脉旁路移植术后出血及输血的影响.中国胸心血管外科临床杂志, 2010, 17(1): 1-5.
7.	Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). [cited 2012 Jan 5]. Available at: http://www.cochrane-handbook.org.
8.	高歌.冠状动脉旁路移植术后双联抗血小板治疗的临床研究.中国协和医科大学, 2009.
9.	Mujanovic E, Nurkic M, Caluk J, et al. The effect of combined clopidogrel and aspirin therapy after off-pump coronary surgery: a pilot study. Innovations (Phila), 2009, 4(5): 265-268.
10.	Sun JC, Teoh KH, Lamy A, et al. Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the preoperative aspirin and postoperative antiplatelets in coronary artery bypass grafting study. Am Heart J, 2010, 160(6): 1178-1184.
11.	Kulik A, Le May MR, Voisine P, et al. Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial. Circulation, 2010, 122(25): 2680-2687.
12.	Mannacio VA, Di Tommaso L, Antignano A, et al. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of coronary artery bypass occlusion after off-pump procedures) randomised study. Heart, 2012, 98(23): 1710-1715.
13.	刘学.氯吡咯雷与阿司匹林对冠状动脉旁路移植术后桥血管中期通畅率的影响研究.中国人民解放军军医进修学院, 2012.
14.	Bhatt DL. Aspirin resistance: more than just a laboratory curiosity. J Am Coll Cardiol, 2004, 43(6): 1127-1129.
15.	Bednar F, Osmancik P, Hlavicka J, et al. Aspirin is insufficient in inhibition of platelet aggregation and thromboxane formation early after coronary artery bypass surgery. J Thromb Thrombolysis, 2009, 27(4): 394-399.
16.	Krasopoulos G, Brister SJ, Beattie WS, et al. Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis. BMJ, 2008, 336(1): 195-198.
17.	王赞鑫, 高菲, 任静, 等.非体外循环冠状动脉旁路移植术后的阿司匹林抵抗.中华胸心血管外科杂志, 2011, 27(8): 477-479.
18.	Bednar F, Osmancik P, Hlavicka J, et al. Aspirin is insufficient in inhibition of platelet aggregation and thromboxane formation early after coronary artery bypass surgery. J Thromb Thrombolysis, 2009, 27(4): 394-399.
19.	Halkos ME, Cooper WA, Petersen R, et al. Early administration of clopidogrel is safe after off-pump coronary artery bypass surgery. Ann Thorac Surg, 2006, 81(3): 815-819.
20.	Goldman S, Zadina K, Moritz T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol, 2004, 44(11): 2149-2156.
21.	Sabik JF, Lytle BW, Blackstone EH, et al. Comparison of Saphenous vein and internal thoracic artery graft patency by coronary system. Ann Thorac Surg, 2005, 79(2): 544-551.
22.	Kim DH, Daskalakis C, Silvestry SC, et al. Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg, 2009, 138(6): 1377-1384.
23.	Sanon S, Lee VV, Elayda M, et al. Use of aspirin versus clopidogrel plus aspirin after coronary artery bypass graft surgery. Clinical and Applied Thrombosis/Hemostasis, 2009, 15(5): 540-544.
24.	Gasparovic H, Petricevic M, Kopjar T, et al. Dual antiplatelet therapy in patients with aspirin resistance following coronary artery bypass grafting: study protocol for a randomized controlled trial. Trials, 2012, 13(1): 148.

1. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Thorac Cardiovasc Surg, 2012, 143(1): 4-34.
2. Stein PD, Schunemann HJ, Dalen JE, et al. Antithrombotic therapy in patients with saphenous vein and internal mammary artery bypass grafts: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004, 126(3 Suppl): 600S-608S.
3. Gurbuz AT, Zia AA, Vuran AC, et al. Postoperative clopidogrel improves mid-term outcome after off-pump coronary artery bypass graft surgery: a prospective study. Eur J Cardiothorac Surg, 2006, 29(2): 190-195.
4. Kulik A, Le May M, Wells GA, et al. The clopidogrel after surgery for coronary artery disease (CASCADE) randomized controlled trial: clopidgorel and aspirin versus aspirin alone after coronary bypass surgery. Curr Control Trials Cardiovasc Med, 2005, 11(6): 15.
5. Patel JH, Stoner JA, Owora A, et al. Evidence for using clopidogrel alone or in addition to aspirin in post coronary artery bypass surgery patients. Am J Cardiol, 2009, 103(12): 1687-1693.
6. 高歌, 胡盛寿, 郑哲, 等.双联抗血小板治疗对冠状动脉旁路移植术后出血及输血的影响.中国胸心血管外科临床杂志, 2010, 17(1): 1-5.
7. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). [cited 2012 Jan 5]. Available at: http://www.cochrane-handbook.org.
8. 高歌.冠状动脉旁路移植术后双联抗血小板治疗的临床研究.中国协和医科大学, 2009.
9. Mujanovic E, Nurkic M, Caluk J, et al. The effect of combined clopidogrel and aspirin therapy after off-pump coronary surgery: a pilot study. Innovations (Phila), 2009, 4(5): 265-268.
10. Sun JC, Teoh KH, Lamy A, et al. Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the preoperative aspirin and postoperative antiplatelets in coronary artery bypass grafting study. Am Heart J, 2010, 160(6): 1178-1184.
11. Kulik A, Le May MR, Voisine P, et al. Aspirin plus clopidogrel versus aspirin alone after coronary artery bypass grafting: the clopidogrel after surgery for coronary artery disease (CASCADE) Trial. Circulation, 2010, 122(25): 2680-2687.
12. Mannacio VA, Di Tommaso L, Antignano A, et al. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of coronary artery bypass occlusion after off-pump procedures) randomised study. Heart, 2012, 98(23): 1710-1715.
13. 刘学.氯吡咯雷与阿司匹林对冠状动脉旁路移植术后桥血管中期通畅率的影响研究.中国人民解放军军医进修学院, 2012.
14. Bhatt DL. Aspirin resistance: more than just a laboratory curiosity. J Am Coll Cardiol, 2004, 43(6): 1127-1129.
15. Bednar F, Osmancik P, Hlavicka J, et al. Aspirin is insufficient in inhibition of platelet aggregation and thromboxane formation early after coronary artery bypass surgery. J Thromb Thrombolysis, 2009, 27(4): 394-399.
16. Krasopoulos G, Brister SJ, Beattie WS, et al. Aspirin "resistance" and risk of cardiovascular morbidity: systematic review and meta-analysis. BMJ, 2008, 336(1): 195-198.
17. 王赞鑫, 高菲, 任静, 等.非体外循环冠状动脉旁路移植术后的阿司匹林抵抗.中华胸心血管外科杂志, 2011, 27(8): 477-479.
18. Bednar F, Osmancik P, Hlavicka J, et al. Aspirin is insufficient in inhibition of platelet aggregation and thromboxane formation early after coronary artery bypass surgery. J Thromb Thrombolysis, 2009, 27(4): 394-399.
19. Halkos ME, Cooper WA, Petersen R, et al. Early administration of clopidogrel is safe after off-pump coronary artery bypass surgery. Ann Thorac Surg, 2006, 81(3): 815-819.
20. Goldman S, Zadina K, Moritz T, et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol, 2004, 44(11): 2149-2156.
21. Sabik JF, Lytle BW, Blackstone EH, et al. Comparison of Saphenous vein and internal thoracic artery graft patency by coronary system. Ann Thorac Surg, 2005, 79(2): 544-551.
22. Kim DH, Daskalakis C, Silvestry SC, et al. Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg, 2009, 138(6): 1377-1384.
23. Sanon S, Lee VV, Elayda M, et al. Use of aspirin versus clopidogrel plus aspirin after coronary artery bypass graft surgery. Clinical and Applied Thrombosis/Hemostasis, 2009, 15(5): 540-544.
24. Gasparovic H, Petricevic M, Kopjar T, et al. Dual antiplatelet therapy in patients with aspirin resistance following coronary artery bypass grafting: study protocol for a randomized controlled trial. Trials, 2012, 13(1): 148.

Chinese Journal of Evidence-Based Medicine

Effectiveness and Safety of Dual Anti-platelet Therapy after Coronary Artery Bypass Grafting: A Meta-Analysis

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