Zhu Y, Zhang W, Dimagli A, Han L, Cheng Z, Mei J, Chen X, Wang X, Zhou Y, Xue Q, Hu J, Tang M, Wang R, Song Y, Kang L, Redfors B, Gaudino M, and Zhao Q
Objective: To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting., Design: Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial., Setting: Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021., Participants: 500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial., Interventions: Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians., Main Outcome Measures: The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings., Results: Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses., Conclusions: Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy., Trial Registration: NCT03987373ClinicalTrials.gov NCT03987373., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from AstraZeneca for the submitted work; YZhu has received personal fees and non-financial support from AstraZeneca, Johnson & Johnson, Medtronic, Novartis, Sanofi, and Chugai and grants from the Science and Technology Commission of Shanghai Municipality and the Shanghai Shenkang Hospital Development Centre; WZ has received personal fees and non-financial support from MSD, Pfizer, Boston Scientific, Cordis, and Becton, Dickinson and Company; LH has received grants from the Science and Technology Commission of Shanghai Municipality. ZC has received personal fees and non-financial support from AstraZeneca, Medtronic, Johnson & Johnson, and Edwards life science and grants from the Science and Technology Commission of Henan Municipality, Henan Provincial Health Commission, Henan Provincial People's Hospital, and Zhengzhou University; JM has received grants from the National Natural Science Foundation of China and the Science and Technology Commission of Shanghai Municipality; XC has received grants from the National Natural Science Foundation of China; XW has received personal fees and non-financial support from AstraZeneca, Johnson & Johnson, and Medtronic and grants from the National Natural Science Foundation of China; QX has received personal fees and non-financial support from Medtronic and Novartis; JH has received personal fees and non-financial support from Medtronic and Johnson & Johnson; MT has received personal fees from Pfizer and grants from the National Natural Science Foundation of China; RW has received personal fees from Novartis. MG has received grants from the National Heart, Lung, and Blood Institute and the Canadian Institutes of Health Research; QZ has received grants, personal fees, and non-financial support from AstraZeneca, personal fees and non-financial support from Medtronic and Johnson & Johnson, and grants from the National Science Foundation of China, Science and Technology Commission of Shanghai Municipality, Shanghai Jiao Tong University, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai Shenkang Hospital Development Centre, and Chugai; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)