Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis

J Card Surg. 2013 Mar;28(2):109-16. doi: 10.1111/jocs.12074.


Background: Anti-platelet therapy is an important component of medical therapy post coronary artery bypass grafting (CABG). While aspirin administration is a Class I indication after CABG, the benefit of concomitant clopidogrel is a controversial issue.

Methods: We searched OVID Medline, Cochrane, Scopus, and EMBASE for randomized control trials and observational studies comparing aspirin ± placebo to aspirin + clopidogrel after CABG.

Results: Eleven articles (five randomized control trials and six observational studies) including 25,728 patients met inclusion criteria. Early saphenous vein graft occlusion was reduced with the use of dual anti-platelet therapy (risk ratio (RR) = 0.59, 95% CI 0.43-0.82, p = 0.02). In-hospital or 30-day mortality was lower with aspirin + clopidogrel (0.8%) compared to aspirin alone (1.9%) (p < 0.0001), while risk of angina or perioperative myocardial infarction was comparable (RR = 0.60, 95% CI 0.31-1.14, p = 0.12). Patients treated with aspirin + clopidogrel demonstrated a trend towards a higher incidence of major bleeding episodes as compared to patients treated with aspirin alone (RR = 1.17, 95% CI 1.00-1.37, p = 0.05). In a pooled analysis of studies involving off-pump CABG compared to aspirin alone, dual anti-platelet therapy reduced the risk of perioperative myocardial infarction and saphenous graft occlusion by 68% (47% to 71%) and 55% (2% to 79%) respectively.

Conclusion: Dual anti-platelet therapy after CABG improved early saphenous vein graft patency, but may increase the risk of bleeding. The use of dual anti-platelet therapy appears to be most beneficial in patients undergoing off-pump CABG. Prospective randomized studies are necessary to determine whether this beneficial effect of dual therapy is also achieved in patients undergoing on pump CABG.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Angina Pectoris / etiology
  • Angina Pectoris / prevention & control
  • Aspirin / therapeutic use*
  • Clopidogrel
  • Coronary Artery Bypass* / mortality
  • Drug Therapy, Combination
  • Graft Occlusion, Vascular / prevention & control*
  • Humans
  • Models, Statistical
  • Myocardial Infarction / etiology
  • Myocardial Infarction / prevention & control
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Postoperative Care / methods*
  • Postoperative Complications / chemically induced
  • Postoperative Complications / prevention & control
  • Postoperative Hemorrhage / chemically induced
  • Randomized Controlled Trials as Topic
  • Ticlopidine / analogs & derivatives*
  • Ticlopidine / therapeutic use
  • Treatment Outcome


  • Platelet Aggregation Inhibitors
  • Clopidogrel
  • Ticlopidine
  • Aspirin