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Coronary artery bypass grafting (CABG) is the commonest form of cardiac surgery, indicated for patients with severe left main and/or multivessel coronary heart disease,1 Medical therapies play important roles in these patients given their significant cardiovascular risk long-term. Guidelines recommend aspirin to be prescribed for all CABG patients and a P2Y12 inhibitor, preferably ticagrelor, for those with an acute coronary syndrome (ACS) within one year before their CABG. With this evidence-base in mind for dual antiplatelet therapy (DAPT), we audited the prescribing patterns following CABG over a one-year period at Auckland City Hospital with the main focus on antiplatelet therapy.

Methods

Consecutive patients undergoing isolated CABG at Auckland City Hospital during July 2017–June 2018 were included from the cardiothoracic surgical unit database. It serves as the tertiary cardiac surgery centre for the Auckland, Counties Manukau, Waitemata and Northland District Health Boards regions with over 1.75 million people, and some contracted cases from the Pacific Islands. Clinical, antiplatelet therapy prescription (aspirin, ticagrelor and clopidogrel) and mortality data were prospectively collected. Operative mortality was defined as death in-hospital or within 30 days of surgery. Prescription medications at the two time-points of discharge of the index CABG admission (excluding in-hospital deaths) and first clinic follow-up with a member of the cardiology team were recorded. Results were presented as mean+/-standard deviation or frequency (percentage) for quantitative and categorical variables respectively.

Results

Cohort characteristics are summarised in Table 1. Mean age was 65.1+/-9.6 years, 90 (18.9%) were female, 293 (61.2%) had ACS as indication and operative mortality occurred in 10 (2.1%). Table 2 shows the prescription rates. Aspirin was prescribed in the vast majority 97.4% at discharge and 96.3% at first clinic appointment. On the other hand, P2Y12 inhibitor was only rarely prescribed in 12/286 (4.2%, with six patients on ticagrelor and six on clopidogrel) and 31/242 (12.8%, 20 patients on ticagrelor and 11 on clopidogrel) of ACS patients at discharge and first clinic follow-up. After discharge P2Y12 inhibitor was initiated by a cardiology nurse specialist for 13 patients and a cardiology doctor for six patients at clinic, the stroke team for one patient, and stopped in one patient.

Table 1: Cohort characteristics and outcomes.

Discussion

In this audit, we found high rates of aspirin prescription for CABG patients, following international guidelines. P2Y12 inhibitors were rarely prescribed in ACS patients at discharge where half received ticagrelor and half clopidogrel, and only slight increases at first clinic follow-up with ticagrelor prescription almost double that of clopidogrel. There is large room for improvement for P2Y12 inhibitor prescription.

DAPT is a cornerstone of ACS management regardless of treatment strategy.2–4 An earlier meta-analysis of five randomised trials found DAPT to reduce venous but not arterial graft occlusion compared to antiplatelet monotherapy in CABG patients.5 Most evidence comes from the large PLATO ACS trial CABG substudy.6 DAPT with ticagrelor significantly reduced major adverse cardiovascular events compared to DAPT with clopidogrel in CABG patients. It also reduced all-cause mortality by half, which was a greater reduction than in PCI or medical therapy patients. Consequently, DAPT is recommended in all ACS patients undergoing CABG in the American guidelines for one year, and European guidelines for six months, one year or longer depending on bleeding risk with IC evidence.2,3 Another recent randomised trial found DAPT with ticagrelor to reduce graft occlusion compared to monotherapy but was underpowered for ischaemic endpoints, which is an important gap that warrants further investigation.7

This is the first New Zealand study reporting DAPT prescription rates after CABG, and similar but few real-world studies overseas have also found low DAPT prescription rates after CABG at 12–29%.8,9 Attention to DAPT prescription in these indicated patients with recent ACS is urgently warranted given the significant benefits, particularly for ticagrelor in secondary prevention of this high-risk group of patients. The main barriers include the need to withhold P2Y12 inhibitors before surgery, concerns about peri-operative and late CABG bleeding, the lack of perceived benefit of DAPT compared to monotherapy, ticagrelor requiring special authority application, patient adherence to an extra medication especially ticagrelor’s twice daily regimen and side effects such as dyspnoea.

Education of cardiology and cardiothoracic surgical teams remains the first key to increasing DAPT prescription in appropriate CABG patients. This needs to occur before the patient is discharged from hospital, as ischaemic risk is highest within the first month meaning greater benefit from DAPT.1–4 Setting prescription target indicators, adding to existing checklists and pathways, and multidisciplinary or nursing rounds can be implemented to achieve this. The first clinic follow-up whether by nurses, junior doctors or specialists in cardiology should then provide a safety-net for those who fall through without DAPT prescription.

This study has some limitations. It is a single-centre retrospective observational study with moderate sample size, but represents our contemporary real-world experience. The rate of community dispensing, patient adherence, actual dosing of medications and prescriptions after the first clinic appointment up to one year were not obtained, as our focus was the antiplatelet therapy prescription practice of inpatient cardiology and cardiothoracic teams to implement guideline recommendations. Data is available by request but not reported for the prescription of other medical therapies as they detract from the DAPT focus of this letter. Short- and longer-term outcomes of the CABG comparing various antiplatelet regimens, and in the setting of concurrently requiring anticoagulation such as atrial fibrillation, warrants further research.

In conclusion, although aspirin was prescribed in almost all CABG patients, P2Y12 inhibitors were rarely prescribed for CABG patients with recent ACS. This highlights lack of awareness of the guideline recommendation for DAPT after CABG that needs urgent attention with both education and policy implementation in order to improve the cardiovascular outcomes of this high-risk group of patients.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Danting Wei, Cardiology Registrar, Department of Cardiology, Middlemore Hospital, Auckland;-Tom Kai Ming Wang, Cardiologist, Department of Cardiology, Middlemore Hospital; and previous cardiology advanced trainee, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland.

Acknowledgements

Correspondence

Dr Tom Kai Ming Wang, Auckland City Hospital, 2 Grafton Road, Grafton, Auckland.

Correspondence Email

twang@adhb.govt.nz

Competing Interests

Nil.

  1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40(2):87–165.
  2. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group ; ESC Committee for Practice Guidelines (CPG) ; ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260.
  3. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68(10):1082–115.
  4. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37(3):267–315.
  5. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013; 112(10):1576–9.
  6. Held C, Asenblad N, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW, Nicolau JC, Scirica BM, Storey RF, Vintila M, Ycas J, Wallentin L . Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol 2011; 57(6):672–84.
  7. Zhao Q, Zhu Y, Xu Z, Cheng Z, Mei J, Chen X, Wang X. Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting: A Randomized Clinical Trial. JAMA 2018; 319(16):1677–1686.
  8. Angerås O, Hasvold P, Thuresson M, Deleskog A, ÖBraun O. Treatment pattern of contemporary dual antiplatelet therapies after acute coronary syndrome: a Swedish nationwide population-based cohort study. Scand Cardiovasc J 2016; 50(2):99–107.
  9. Mori M, Shioda K, Yun JJ, Mangi AA, Darr U, Geirsson A. Pattern and predictors of dual antiplatelet use following coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2018; 155:632–638.
  10. Lip GY , Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, Halvorsen S, Lau D, Lopez-Cabanillas N, Lettino M, Marin F, Obel I, Rubboli A, Storey RF, Valgimigli M, Huber K; ESC Scientific Document Group. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2019; 21(2):192–193.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Coronary artery bypass grafting (CABG) is the commonest form of cardiac surgery, indicated for patients with severe left main and/or multivessel coronary heart disease,1 Medical therapies play important roles in these patients given their significant cardiovascular risk long-term. Guidelines recommend aspirin to be prescribed for all CABG patients and a P2Y12 inhibitor, preferably ticagrelor, for those with an acute coronary syndrome (ACS) within one year before their CABG. With this evidence-base in mind for dual antiplatelet therapy (DAPT), we audited the prescribing patterns following CABG over a one-year period at Auckland City Hospital with the main focus on antiplatelet therapy.

Methods

Consecutive patients undergoing isolated CABG at Auckland City Hospital during July 2017–June 2018 were included from the cardiothoracic surgical unit database. It serves as the tertiary cardiac surgery centre for the Auckland, Counties Manukau, Waitemata and Northland District Health Boards regions with over 1.75 million people, and some contracted cases from the Pacific Islands. Clinical, antiplatelet therapy prescription (aspirin, ticagrelor and clopidogrel) and mortality data were prospectively collected. Operative mortality was defined as death in-hospital or within 30 days of surgery. Prescription medications at the two time-points of discharge of the index CABG admission (excluding in-hospital deaths) and first clinic follow-up with a member of the cardiology team were recorded. Results were presented as mean+/-standard deviation or frequency (percentage) for quantitative and categorical variables respectively.

Results

Cohort characteristics are summarised in Table 1. Mean age was 65.1+/-9.6 years, 90 (18.9%) were female, 293 (61.2%) had ACS as indication and operative mortality occurred in 10 (2.1%). Table 2 shows the prescription rates. Aspirin was prescribed in the vast majority 97.4% at discharge and 96.3% at first clinic appointment. On the other hand, P2Y12 inhibitor was only rarely prescribed in 12/286 (4.2%, with six patients on ticagrelor and six on clopidogrel) and 31/242 (12.8%, 20 patients on ticagrelor and 11 on clopidogrel) of ACS patients at discharge and first clinic follow-up. After discharge P2Y12 inhibitor was initiated by a cardiology nurse specialist for 13 patients and a cardiology doctor for six patients at clinic, the stroke team for one patient, and stopped in one patient.

Table 1: Cohort characteristics and outcomes.

Discussion

In this audit, we found high rates of aspirin prescription for CABG patients, following international guidelines. P2Y12 inhibitors were rarely prescribed in ACS patients at discharge where half received ticagrelor and half clopidogrel, and only slight increases at first clinic follow-up with ticagrelor prescription almost double that of clopidogrel. There is large room for improvement for P2Y12 inhibitor prescription.

DAPT is a cornerstone of ACS management regardless of treatment strategy.2–4 An earlier meta-analysis of five randomised trials found DAPT to reduce venous but not arterial graft occlusion compared to antiplatelet monotherapy in CABG patients.5 Most evidence comes from the large PLATO ACS trial CABG substudy.6 DAPT with ticagrelor significantly reduced major adverse cardiovascular events compared to DAPT with clopidogrel in CABG patients. It also reduced all-cause mortality by half, which was a greater reduction than in PCI or medical therapy patients. Consequently, DAPT is recommended in all ACS patients undergoing CABG in the American guidelines for one year, and European guidelines for six months, one year or longer depending on bleeding risk with IC evidence.2,3 Another recent randomised trial found DAPT with ticagrelor to reduce graft occlusion compared to monotherapy but was underpowered for ischaemic endpoints, which is an important gap that warrants further investigation.7

This is the first New Zealand study reporting DAPT prescription rates after CABG, and similar but few real-world studies overseas have also found low DAPT prescription rates after CABG at 12–29%.8,9 Attention to DAPT prescription in these indicated patients with recent ACS is urgently warranted given the significant benefits, particularly for ticagrelor in secondary prevention of this high-risk group of patients. The main barriers include the need to withhold P2Y12 inhibitors before surgery, concerns about peri-operative and late CABG bleeding, the lack of perceived benefit of DAPT compared to monotherapy, ticagrelor requiring special authority application, patient adherence to an extra medication especially ticagrelor’s twice daily regimen and side effects such as dyspnoea.

Education of cardiology and cardiothoracic surgical teams remains the first key to increasing DAPT prescription in appropriate CABG patients. This needs to occur before the patient is discharged from hospital, as ischaemic risk is highest within the first month meaning greater benefit from DAPT.1–4 Setting prescription target indicators, adding to existing checklists and pathways, and multidisciplinary or nursing rounds can be implemented to achieve this. The first clinic follow-up whether by nurses, junior doctors or specialists in cardiology should then provide a safety-net for those who fall through without DAPT prescription.

This study has some limitations. It is a single-centre retrospective observational study with moderate sample size, but represents our contemporary real-world experience. The rate of community dispensing, patient adherence, actual dosing of medications and prescriptions after the first clinic appointment up to one year were not obtained, as our focus was the antiplatelet therapy prescription practice of inpatient cardiology and cardiothoracic teams to implement guideline recommendations. Data is available by request but not reported for the prescription of other medical therapies as they detract from the DAPT focus of this letter. Short- and longer-term outcomes of the CABG comparing various antiplatelet regimens, and in the setting of concurrently requiring anticoagulation such as atrial fibrillation, warrants further research.

In conclusion, although aspirin was prescribed in almost all CABG patients, P2Y12 inhibitors were rarely prescribed for CABG patients with recent ACS. This highlights lack of awareness of the guideline recommendation for DAPT after CABG that needs urgent attention with both education and policy implementation in order to improve the cardiovascular outcomes of this high-risk group of patients.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Danting Wei, Cardiology Registrar, Department of Cardiology, Middlemore Hospital, Auckland;-Tom Kai Ming Wang, Cardiologist, Department of Cardiology, Middlemore Hospital; and previous cardiology advanced trainee, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland.

Acknowledgements

Correspondence

Dr Tom Kai Ming Wang, Auckland City Hospital, 2 Grafton Road, Grafton, Auckland.

Correspondence Email

twang@adhb.govt.nz

Competing Interests

Nil.

  1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40(2):87–165.
  2. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group ; ESC Committee for Practice Guidelines (CPG) ; ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260.
  3. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68(10):1082–115.
  4. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37(3):267–315.
  5. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013; 112(10):1576–9.
  6. Held C, Asenblad N, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW, Nicolau JC, Scirica BM, Storey RF, Vintila M, Ycas J, Wallentin L . Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol 2011; 57(6):672–84.
  7. Zhao Q, Zhu Y, Xu Z, Cheng Z, Mei J, Chen X, Wang X. Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting: A Randomized Clinical Trial. JAMA 2018; 319(16):1677–1686.
  8. Angerås O, Hasvold P, Thuresson M, Deleskog A, ÖBraun O. Treatment pattern of contemporary dual antiplatelet therapies after acute coronary syndrome: a Swedish nationwide population-based cohort study. Scand Cardiovasc J 2016; 50(2):99–107.
  9. Mori M, Shioda K, Yun JJ, Mangi AA, Darr U, Geirsson A. Pattern and predictors of dual antiplatelet use following coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2018; 155:632–638.
  10. Lip GY , Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, Halvorsen S, Lau D, Lopez-Cabanillas N, Lettino M, Marin F, Obel I, Rubboli A, Storey RF, Valgimigli M, Huber K; ESC Scientific Document Group. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2019; 21(2):192–193.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Coronary artery bypass grafting (CABG) is the commonest form of cardiac surgery, indicated for patients with severe left main and/or multivessel coronary heart disease,1 Medical therapies play important roles in these patients given their significant cardiovascular risk long-term. Guidelines recommend aspirin to be prescribed for all CABG patients and a P2Y12 inhibitor, preferably ticagrelor, for those with an acute coronary syndrome (ACS) within one year before their CABG. With this evidence-base in mind for dual antiplatelet therapy (DAPT), we audited the prescribing patterns following CABG over a one-year period at Auckland City Hospital with the main focus on antiplatelet therapy.

Methods

Consecutive patients undergoing isolated CABG at Auckland City Hospital during July 2017–June 2018 were included from the cardiothoracic surgical unit database. It serves as the tertiary cardiac surgery centre for the Auckland, Counties Manukau, Waitemata and Northland District Health Boards regions with over 1.75 million people, and some contracted cases from the Pacific Islands. Clinical, antiplatelet therapy prescription (aspirin, ticagrelor and clopidogrel) and mortality data were prospectively collected. Operative mortality was defined as death in-hospital or within 30 days of surgery. Prescription medications at the two time-points of discharge of the index CABG admission (excluding in-hospital deaths) and first clinic follow-up with a member of the cardiology team were recorded. Results were presented as mean+/-standard deviation or frequency (percentage) for quantitative and categorical variables respectively.

Results

Cohort characteristics are summarised in Table 1. Mean age was 65.1+/-9.6 years, 90 (18.9%) were female, 293 (61.2%) had ACS as indication and operative mortality occurred in 10 (2.1%). Table 2 shows the prescription rates. Aspirin was prescribed in the vast majority 97.4% at discharge and 96.3% at first clinic appointment. On the other hand, P2Y12 inhibitor was only rarely prescribed in 12/286 (4.2%, with six patients on ticagrelor and six on clopidogrel) and 31/242 (12.8%, 20 patients on ticagrelor and 11 on clopidogrel) of ACS patients at discharge and first clinic follow-up. After discharge P2Y12 inhibitor was initiated by a cardiology nurse specialist for 13 patients and a cardiology doctor for six patients at clinic, the stroke team for one patient, and stopped in one patient.

Table 1: Cohort characteristics and outcomes.

Discussion

In this audit, we found high rates of aspirin prescription for CABG patients, following international guidelines. P2Y12 inhibitors were rarely prescribed in ACS patients at discharge where half received ticagrelor and half clopidogrel, and only slight increases at first clinic follow-up with ticagrelor prescription almost double that of clopidogrel. There is large room for improvement for P2Y12 inhibitor prescription.

DAPT is a cornerstone of ACS management regardless of treatment strategy.2–4 An earlier meta-analysis of five randomised trials found DAPT to reduce venous but not arterial graft occlusion compared to antiplatelet monotherapy in CABG patients.5 Most evidence comes from the large PLATO ACS trial CABG substudy.6 DAPT with ticagrelor significantly reduced major adverse cardiovascular events compared to DAPT with clopidogrel in CABG patients. It also reduced all-cause mortality by half, which was a greater reduction than in PCI or medical therapy patients. Consequently, DAPT is recommended in all ACS patients undergoing CABG in the American guidelines for one year, and European guidelines for six months, one year or longer depending on bleeding risk with IC evidence.2,3 Another recent randomised trial found DAPT with ticagrelor to reduce graft occlusion compared to monotherapy but was underpowered for ischaemic endpoints, which is an important gap that warrants further investigation.7

This is the first New Zealand study reporting DAPT prescription rates after CABG, and similar but few real-world studies overseas have also found low DAPT prescription rates after CABG at 12–29%.8,9 Attention to DAPT prescription in these indicated patients with recent ACS is urgently warranted given the significant benefits, particularly for ticagrelor in secondary prevention of this high-risk group of patients. The main barriers include the need to withhold P2Y12 inhibitors before surgery, concerns about peri-operative and late CABG bleeding, the lack of perceived benefit of DAPT compared to monotherapy, ticagrelor requiring special authority application, patient adherence to an extra medication especially ticagrelor’s twice daily regimen and side effects such as dyspnoea.

Education of cardiology and cardiothoracic surgical teams remains the first key to increasing DAPT prescription in appropriate CABG patients. This needs to occur before the patient is discharged from hospital, as ischaemic risk is highest within the first month meaning greater benefit from DAPT.1–4 Setting prescription target indicators, adding to existing checklists and pathways, and multidisciplinary or nursing rounds can be implemented to achieve this. The first clinic follow-up whether by nurses, junior doctors or specialists in cardiology should then provide a safety-net for those who fall through without DAPT prescription.

This study has some limitations. It is a single-centre retrospective observational study with moderate sample size, but represents our contemporary real-world experience. The rate of community dispensing, patient adherence, actual dosing of medications and prescriptions after the first clinic appointment up to one year were not obtained, as our focus was the antiplatelet therapy prescription practice of inpatient cardiology and cardiothoracic teams to implement guideline recommendations. Data is available by request but not reported for the prescription of other medical therapies as they detract from the DAPT focus of this letter. Short- and longer-term outcomes of the CABG comparing various antiplatelet regimens, and in the setting of concurrently requiring anticoagulation such as atrial fibrillation, warrants further research.

In conclusion, although aspirin was prescribed in almost all CABG patients, P2Y12 inhibitors were rarely prescribed for CABG patients with recent ACS. This highlights lack of awareness of the guideline recommendation for DAPT after CABG that needs urgent attention with both education and policy implementation in order to improve the cardiovascular outcomes of this high-risk group of patients.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Danting Wei, Cardiology Registrar, Department of Cardiology, Middlemore Hospital, Auckland;-Tom Kai Ming Wang, Cardiologist, Department of Cardiology, Middlemore Hospital; and previous cardiology advanced trainee, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland.

Acknowledgements

Correspondence

Dr Tom Kai Ming Wang, Auckland City Hospital, 2 Grafton Road, Grafton, Auckland.

Correspondence Email

twang@adhb.govt.nz

Competing Interests

Nil.

  1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40(2):87–165.
  2. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN; ESC Scientific Document Group ; ESC Committee for Practice Guidelines (CPG) ; ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39(3):213–260.
  3. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68(10):1082–115.
  4. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, Bax JJ, Borger MA, Brotons C, Chew DP, Gencer B, Hasenfuss G, Kjeldsen K, Lancellotti P, Landmesser U, Mehilli J, Mukherjee D, Storey RF, Windecker S; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37(3):267–315.
  5. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013; 112(10):1576–9.
  6. Held C, Asenblad N, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW, Nicolau JC, Scirica BM, Storey RF, Vintila M, Ycas J, Wallentin L . Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol 2011; 57(6):672–84.
  7. Zhao Q, Zhu Y, Xu Z, Cheng Z, Mei J, Chen X, Wang X. Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting: A Randomized Clinical Trial. JAMA 2018; 319(16):1677–1686.
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