What is the recommended antiplatelet therapy for a patient with a history of Coronary Artery Bypass Graft (CABG) and Barrett's esophagus?

Antiplatelet Therapy for CABG Patient with Barrett's Esophagus

In patients with a history of Coronary Artery Bypass Graft (CABG) and Barrett's esophagus, single antiplatelet therapy with low-dose aspirin (75-100 mg daily) is recommended as the primary long-term therapy, with careful consideration of gastrointestinal bleeding risk requiring proton pump inhibitor co-therapy. 1

Antiplatelet Recommendations After CABG

Standard Recommendations

• Low-dose aspirin (75-100 mg daily) is recommended lifelong after CABG to improve vein graft patency and reduce major adverse cardiovascular events 1
• Aspirin should be continued until the day of CABG and restarted as soon as there is no concern about bleeding, ideally within 24 hours after surgery 1
• For patients with Acute Coronary Syndrome (ACS) who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after the ACS event 1

Special Considerations for Barrett's Esophagus

• Barrett's esophagus represents a significant risk factor for gastrointestinal bleeding when on antiplatelet therapy 1
• Proton pump inhibitor (PPI) therapy is strongly recommended in combination with antiplatelet therapy for patients with Barrett's esophagus to reduce the risk of upper gastrointestinal bleeding 1
• When selecting a PPI, consider potential drug interactions with clopidogrel (particularly omeprazole and esomeprazole may reduce clopidogrel's effectiveness) 1

Duration of Therapy Based on Clinical Scenario

For Patients with Recent ACS Who Underwent CABG

• P2Y12 inhibitor therapy (clopidogrel) should be resumed after CABG to complete a total of 12 months of DAPT after the ACS event 1
• After completing 12 months of DAPT, transition to aspirin monotherapy is recommended for long-term therapy 1

For Patients with Stable Ischemic Heart Disease (SIHD) Who Underwent CABG

• DAPT with clopidogrel for 12 months after CABG may be reasonable to improve vein graft patency (Class IIb recommendation) 1
• After 12 months, transition to aspirin monotherapy is typically recommended for long-term therapy 1
• In patients with high bleeding risk (such as those with Barrett's esophagus), the benefits of extended DAPT must be carefully weighed against the increased bleeding risk 1

P2Y12 Inhibitor Selection When DAPT is Indicated

• Clopidogrel is the preferred P2Y12 inhibitor for CABG patients when DAPT is indicated 1, 2
• Ticagrelor may be considered as an alternative to clopidogrel in ACS patients, as it has shown reduced cardiovascular mortality compared to clopidogrel in post-CABG patients 1, 2
• Prasugrel should not be administered to patients with prior history of stroke or TIA 1

Management Algorithm for CABG Patient with Barrett's Esophagus

1. Immediate post-CABG period:

   • Resume low-dose aspirin (75-100 mg daily) within 24 hours after surgery if no bleeding concerns 1
   • Start PPI therapy concurrently with antiplatelet therapy 1

2. If patient had recent ACS:

   • Resume P2Y12 inhibitor (preferably clopidogrel) as soon as safe after CABG 1
   • Continue DAPT to complete 12 months of therapy after the ACS event 1
   • Monitor closely for signs of GI bleeding 1

3. If patient had CABG for stable CAD:

   • Consider DAPT with clopidogrel for up to 12 months to improve graft patency 1
   • If bleeding risk is high due to Barrett's esophagus, consider shorter duration of DAPT or aspirin monotherapy 1

4. Long-term management:

   • After completing the recommended DAPT duration, continue lifelong aspirin monotherapy 1
   • Continue PPI therapy indefinitely to protect against GI bleeding 1
   • Regular monitoring for both cardiovascular events and GI complications 1

Bleeding Risk Mitigation

• Use the lowest effective dose of aspirin (75-100 mg daily) 1
• Mandatory co-prescription of a PPI for patients with Barrett's esophagus on any antiplatelet therapy 1
• Avoid NSAIDs and high alcohol consumption which may increase bleeding risk 1
• Regular endoscopic surveillance as appropriate for Barrett's esophagus management 1

Key Considerations for Antiplatelet Therapy Decisions

• The presence of Barrett's esophagus significantly increases the risk of upper GI bleeding with antiplatelet therapy 1
• The benefit of extended DAPT must be balanced against the increased bleeding risk 1
• In most cases, long-term aspirin monotherapy with PPI co-therapy represents the optimal balance between thrombotic protection and bleeding risk 1