Benefits of De-escalated Dual Antiplatelet Therapy in Post-CABG Patients
Recent research has unveiled significant advantages of a de-escalated dual antiplatelet therapy (DAPT) approach for patients who have undergone coronary artery bypass grafting (CABG). This finding was presented during a Hot Line session at ESC Congress 2025 in Madrid.
Traditional DAPT, which includes the use of aspirin and a P2Y12 inhibitor, has been the standard approach in managing patients post-CABG. However, this standard treatment comes with drawbacks, particularly an increased risk of bleeding. The study revealed that adapting a de-escalated strategy--employing DAPT for only one to three months followed by aspirin monotherapy for the remainder of the year--offers comparable outcomes in terms of graft occlusion rates while significantly reducing clinically relevant bleeding incidents.
Coronary artery bypass grafting remains a vital procedure for patients with severe coronary artery disease, yet the failure rates of saphenous vein grafts, which are commonly used during the surgery, remain a concern. Reports indicate that between 3% and 12% of these grafts may occlude before hospital discharge, and 8% to 25% may fail within the first year.
Dr. Xin Yuan, the principal investigator of the TOP-CABG trial, emphasized that while a full year of DAPT has shown to lower the risk of graft failure, it also heightens the risk of bleeding complications. He pointed out that the initial three months following CABG is a critical period for thrombotic events, similar to what is observed after percutaneous coronary intervention (PCI). Despite this, there has been a notable lack of studies investigating de-escalated DAPT strategies in the context of CABG.
The TOP-CABG trial was a rigorously designed double-blind, parallel-controlled randomized study involving 13 hospitals across China. The study recruited patients aged 18 to 80 who were slated for their first CABG, necessitating at least one saphenous vein graft. Participants were randomly assigned to receive either the de-escalated DAPT regimen or the standard DAPT treatment.
With a primary endpoint focusing on the rate of graft occlusion within one year post-surgery, researchers utilized coronary computed tomography angiography or coronary angiography to assess outcomes. The results demonstrated that 10.79% of grafts in the de-escalated DAPT group experienced occlusion compared to 11.19% in the standard DAPT group, thus confirming noninferiority between the two approaches.
In terms of safety, clinically relevant bleeding was significantly less frequent in the de-escalated DAPT group, occurring in 8.26% of patients compared to 13.19% in the standard group. This marked improvement highlights the potential benefits of a tailored treatment strategy that balances graft protection with bleeding risks.
Secondary outcomes, including rates of graft failure and major adverse cardiac events, showed no significant differences between the two treatment groups, reinforcing the primary findings of the study.
Dr. Yuan concluded that the findings from the largest CABG trial to date indicate that a de-escalation strategy may provide a more favorable balance between securing graft patency and minimizing the risk of bleeding complications. These results are poised to influence future clinical guidelines regarding the duration of DAPT in the early postoperative phase following CABG surgery.