If the patient is undergoing CABG surgery as part of the management strategy for ACS, at least 12 months of treatment with DAPT is indicated after surgery, and ticagrelor is recommended over clopidogrel if the patient is not at high risk of bleeding.14 The goal of DAPT after an ACS event is to treat the underlying milieu of atherothrombosis and prevent future plaque-rupture events like myocardial infarction regardless of revascularization strategy.
In the setting of CABG surgery for non-ACS indications (eg, stable angina), the use of DAPT may be of limited value and may be better guided by considering the mechanisms of SVG occlusion. SVG failure is a multifactorial process that involves acute thrombosis, intimal hyperplasia, inflammation, and atherosclerosis.
Such strategies have not yet been tested and require evaluation in adequately powered randomized trials. Until such data are available, the decision regarding DAPT after CABG surgery should be limited to the ACS population, with consideration of an individual patient’s risk of SVG failure vs their risk of bleeding.
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