Is ticagrelor (a P2Y12 inhibitor) indicated in patients post Coronary Artery Bypass Grafting (CABG)?

Ticagrelor Use in Post-CABG Patients

Ticagrelor is not routinely indicated for patients after coronary artery bypass grafting (CABG) surgery, with aspirin monotherapy remaining the standard of care for most post-CABG patients. 1, 2

Standard Antiplatelet Therapy After CABG

For All CABG Patients:

• First-line therapy: Low-dose aspirin (81-100 mg daily) initiated within 6 hours after CABG and continued indefinitely 2
• For aspirin-intolerant patients: Clopidogrel 75 mg daily is the recommended alternative 2, 1

Specific Post-CABG Scenarios Where P2Y12 Inhibitors May Be Used

1. Post-ACS CABG Patients:

• For patients who underwent CABG for acute coronary syndrome (ACS), resuming P2Y12 inhibitor therapy to complete 12 months of DAPT is recommended 2
• In this setting, clopidogrel is the preferred P2Y12 inhibitor after CABG 2
• Ticagrelor may be considered in specific high-risk ACS patients post-CABG, as it demonstrated reduction in cardiovascular mortality compared to clopidogrel in the PLATO trial subgroup analysis 3

2. Vein Graft Patency Considerations:

• For stable ischemic heart disease patients, DAPT with clopidogrel plus aspirin for 12 months after CABG may be reasonable to improve vein graft patency (Class IIb recommendation) 2
• Recent meta-analysis shows ticagrelor decreased risk of saphenous vein graft occlusion at 1 year compared to non-ticagrelor therapy 4, but the TiCAB trial showed no significant difference in major cardiovascular events between ticagrelor and aspirin monotherapy 5

Important Considerations for P2Y12 Inhibitor Use

Bleeding Risk:

• DAPT significantly increases both major and minor bleeding compared to aspirin alone 2
• For patients at increased risk of gastrointestinal bleeding, proton pump inhibitors should be used 1, 2

Preoperative Management:

• If possible, ticagrelor should be discontinued for at least 5 days before elective CABG 1
• For urgent CABG, ticagrelor should be discontinued for at least 24 hours to reduce major bleeding 1
• The more rapid recovery of platelet function seen in ticagrelor pharmacokinetic studies did not translate to lower bleeding risk compared with clopidogrel when CABG was performed early (less than 5 days) after drug discontinuation 1

Emerging Evidence

Recent research is exploring shorter durations of DAPT post-CABG:

• The ongoing ODIN trial is evaluating 1-month dual antiplatelet therapy with ticagrelor plus low-dose aspirin after CABG in patients with chronic coronary syndromes 6
• This approach may provide better risk-benefit profile by targeting the highest-risk period for graft thrombosis while limiting bleeding risk

Algorithm for P2Y12 Inhibitor Use After CABG

1. Standard approach: Aspirin monotherapy (81-100 mg daily) for all post-CABG patients
2. For ACS patients who underwent CABG:
   • Resume P2Y12 inhibitor (preferably clopidogrel) plus aspirin to complete 12 months of DAPT
   • Consider ticagrelor in high-risk patients with prior ACS if bleeding risk is acceptable
3. For stable coronary disease patients with high risk of graft failure:
   • Consider adding clopidogrel to aspirin for up to 12 months
   • Reserve ticagrelor for specific high-risk scenarios where benefit may outweigh bleeding risk

In conclusion, while ticagrelor has shown some benefit in specific post-CABG populations, particularly those with ACS, it is not routinely indicated for all post-CABG patients, with aspirin monotherapy remaining the standard approach for most patients.