Clinical Question: In patients undergoing CABG for acute coronary syndrome, does one year of dual antiplatelet therapy with ticagrelor plus aspirin improve clinical outcomes compared with aspirin alone?
Background: Current U.S. and European guidelines recommend dual antiplatelet therapy (DAPT) after CABG for patients with acute coronary syndrome, despite limited direct evidence in this population. These recommendations are largely extrapolated from percutaneous coronary intervention (PCI) trials and observational studies, while randomized data specific to CABG patients remain sparse. Determining whether DAPT improves outcomes after surgical revascularization is clinically important, especially given concerns about postoperative bleeding.
Study Design: Multinational, open-label, registry-based, randomized, controlled trial
Setting: Twenty-two hospitals across five Nordic countries
Synopsis: In this registry-based randomized trial, 2,201 adults undergoing CABG for acute coronary syndrome were assigned to ticagrelor plus aspirin or aspirin alone for one year. The primary composite outcome of death, myocardial infarction, stroke, or repeat revascularization occurred in 4.8% of the ticagrelor-plus-aspirin group versus 4.6% of the aspirin-alone group (hazard ratio [HR], 1.06; CI, 0.72 to 1.56), showing no ischemic benefit with dual therapy. Major bleeding occurred more frequently with ticagrelor plus aspirin (4.9% versus 2.0%; HR, 2.50; CI, 1.52-4.11), and severe dyspnea was also increased (18.2% versus 6.4%). Treatment adherence was lower in the ticagrelor group, with only 64% completing therapy at one year. These findings challenge current guideline recommendations for routine DAPT after CABG in acute coronary syndrome patients and suggest aspirin monotherapy may be safer without compromising efficacy.
Bottom Line: Among patients undergoing CABG for acute coronary syndrome, ticagrelor plus aspirin did not improve cardiovascular outcomes compared with aspirin alone and significantly increased bleeding.
Citation: Jeppsson A, et al. Ticagrelor and aspirin or aspirin alone after coronary surgery for acute coronary syndrome. N Engl J Med. 2025;393(23):2313-2323. doi:10.1056/NEJMoa2508026.
Dr. Pristoop
Dr. Pristoop is an academic hospitalist in the division of hospital medicine at MedStar Washington Hospital Center and an assistant professor of medicine at Georgetown University School of Medicine, both in Washington, D.C.