Original title: Effect of ticagrelor on the outcomes of patients with prior coronary artery bypass grafo surgery: Inssights from th PLATelet inhibition and patients outcomes (PLATO) trial. Reference: Emmanouil S. Brilakis, et al. Am Heart J 2013;166:474-80

The bridge venous occlusion is a common finding in patients with previous CABG presenting with acute coronary syndrome without ST segment elevation, showing increased risk of cardiovascular events and death. In the PLATO study 18613 patients were included and randomized to ticagrelor versus clopidogrel. Out of the total, 1133 ( 6.1 %) experienced a history of CABG .

The primary endpoint of this sub-study was to compare the rate of cardiovascular death , myocardial infarction and stroke of ticagrelor versus clopidogrel in patients with prior myocardial revascularization surgery .

The median time between surgery and coronary event was 9 (5-13 ) years for those patients showed significantly more risk factors and comorbidities (age , diabetes , stroke , previous angioplasty , and previous infarction ), which doubled their risk of cardiovascular outcomes compared to those not operated. In those receiving angioplasty ( 31 % to venous graft and to 17 % native arteries ) glycoprotein IIb IIIa was used more frequently. Ticagrelor reduced the primary end point (cardiovascular death, heart attack and stroke) similar in the patients with a history of surgery (19.6 % ticagrelor versus 21.4 % clopidogrel, HR 0.91; CI 0.67 to 1.24 ) compared with those patients without previous surgery ( 9.2 % ticagrelor versus 11.0 % clopidogrel, HR 0.86; CI 0.77 to 0.96 ), P = 0.73 for interaction of previous surgery. Major bleeding was similar with ticagrelor versus clopidogrel in patients with surgery (8.1 % versus 8.7 %, HR , 0.89 ) compared with patients without surgery ( 11.8 % versus 11.4 %, HR, 1.08 ) , P = 0.46 for interaction previous surgery.

Conclusion: 

Patients with previous surgery history, experiencing acute coronary syndromes are at high risk of death and adverse cardiac events . Ticagrelor, similar to non-surgical patients, is associated with a reduction of ischemic events without increasing the risk of bleeding compared with clopidogrel. 

Editorial Comment:

This sub study that analyzed a small cohort of higher risk , showed that use of ticagrelor was beneficial without increasing bleeding. The small population with previous surgery ( only 6.1 % of total) limits the power of the study , so the results, when comparing subgroups should be interpreted in this context. 

Courtesy of Dr Carlos Fava.
Interventional Cardiologist.
Favaloro Foundation. Buenos Aires, Argentina.

Dr. Carlos Fava para SOLACI.ORG