title: Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis.
abstract: BACKGROUND
  Anti-platelet therapy is an important component of medical therapy post coronary artery bypass grafting (CABG). While aspirin administration is a Class I indication after CABG, the benefit of concomitant clopidogrel is a controversial issue.
  
  
  METHODS
  We searched OVID Medline, Cochrane, Scopus, and EMBASE for randomized control trials and observational studies comparing aspirin ± placebo to aspirin + clopidogrel after CABG.
  
  
  RESULTS
  Eleven articles (five randomized control trials and six observational studies) including 25,728 patients met inclusion criteria. Early saphenous vein graft occlusion was reduced with the use of dual anti-platelet therapy (risk ratio (RR) = 0.59, 95% CI 0.43-0.82, p = 0.02). In-hospital or 30-day mortality was lower with aspirin + clopidogrel (0.8%) compared to aspirin alone (1.9%) (p < 0.0001), while risk of angina or perioperative myocardial infarction was comparable (RR = 0.60, 95% CI 0.31-1.14, p = 0.12). Patients treated with aspirin + clopidogrel demonstrated a trend towards a higher incidence of major bleeding episodes as compared to patients treated with aspirin alone (RR = 1.17, 95% CI 1.00-1.37, p = 0.05). In a pooled analysis of studies involving off-pump CABG compared to aspirin alone, dual anti-platelet therapy reduced the risk of perioperative myocardial infarction and saphenous graft occlusion by 68% (47% to 71%) and 55% (2% to 79%) respectively.
  
  
  CONCLUSIONS
  Dual anti-platelet therapy after CABG improved early saphenous vein graft patency, but may increase the risk of bleeding. The use of dual anti-platelet therapy appears to be most beneficial in patients undergoing off-pump CABG. Prospective randomized studies are necessary to determine whether this beneficial effect of dual therapy is also achieved in patients undergoing on pump CABG.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA. deo.salil@mayo.edu
authors.forename: Salil V
authors.initials: SV
authors.lastname: Deo
authors.forename: Shannon M
authors.initials: SM
authors.lastname: Dunlay
authors.forename: Ishan K
authors.initials: IK
authors.lastname: Shah
authors.forename: Salah E
authors.initials: SE
authors.lastname: Altarabsheh
authors.forename: Patricia J
authors.initials: PJ
authors.lastname: Erwin
authors.forename: Barry A
authors.initials: BA
authors.lastname: Boilson
authors.forename: Soon J
authors.initials: SJ
authors.lastname: Park
authors.forename: Lyle D
authors.initials: LD
authors.lastname: Joyce
mesh_terms: D000787:Angina Pectoris / Q000209:etiology / Q000517:prevention & control; D001241:Aspirin / Q000627:therapeutic use*; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000401:mortality; D004359:Drug Therapy, Combination; D006083:Graft Occlusion, Vascular / Q000517:prevention & control*; D006801:Humans; D015233:Models, Statistical; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000139:chemically induced / Q000517:prevention & control; D019106:Postoperative Hemorrhage / Q000139:chemically induced; D016032:Randomized Controlled Trials as Topic; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin