DAPT vs. Monotherapy: The Dilemma Remains After Surgery

Patients who undergo myocardial revascularization surgery and are discharged on dual antiplatelet therapy (DAPT)—aspirin plus clopidogrel—have a lower risk of major cardiovascular and cerebral events than patients on aspirin monotherapy.

Furthermore, the risk of bleeding is not increased for those receiving DAPT.

This information comes from a registry of over 18,000 patients recently published in the Journal of the American Heart Association (JAHA).

This contemporary registry included all patients who underwent isolated myocardial revascularization surgery between 2013 and 2017. Of all patients, 60.1% were discharged on DAPT—clopidogrel plus aspirin—, while the rest received aspirin monotherapy.

Multiple adjustments were made to avoid confounding variables between DAPT indication and other variables that could affect the results.

Patients who received DAPT had a lower incidence of the composite endpoint (all-cause mortality, myocardial infarction, stroke, or repeat revascularization) at 6 months compared with those who received aspirin monotherapy (2.9% vs. 4.2%; hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.55 to 0.77; p < 0,001).

This difference was still significant when considering each separate variable, namely, all-cause mortality (HR: 0.61; 95% CI: 0.41 to 0.90), infarction (HR: 0.55; 95% CI: 0.40 to 0.74), and stroke (HR: 0.58; 95% CI: 0.46 to 0.74).

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The incidence of major bleeding was similar between DAPT and aspirin monotherapy groups. No difference was observed when analyzing multiple risk subgroups.

Conclusion

Patients who undergo myocardial revascularization surgery find benefit in 6 months of DAPT with aspirin plus clopidogrel compared with those who receive aspirin monotherapy. This strategy translated into a significant reduction in major cardiovascular and cerebral events, and it did not have a negative effect related to bleeding.

Original Title: Dual Antiplatelet Therapy with Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Reference: Jianyu Qu et al. J Am Heart Assoc. 2021 Jun;10(11):e020413. doi: 10.1161/JAHA.120.020413.

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