Ticagrelor-Based antiplatelet therapy versus aspirin alone after coronary artery bypass grafting: A systematic review and Meta-Analysis with trial sequential analysis.

introductionCoronary artery bypass grafting (CABG) is a common surgical treatment for coronary artery disease; however, long-term success is limited by saphenous vein graft (SVG) occlusion. Aspirin remains the standard lifelong antiplatelet therapy; however, graft failure and adverse events persist after its use. More potent agents, such as ticagrelor, have been proposed, although the evidence is inconsistent, and concerns about bleeding risk remain. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing ticagrelor-based therapy with aspirin monotherapy in patients who underwent CABG. A comprehensive literature search of major databases was performed until August 2025. The primary endpoints were major bleeding, MACE, and all-cause mortality. The secondary outcomes included saphenous vein graft failure, stroke, myocardial infarction, and repeat revascularization. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Five randomized controlled trials comprising 4,208 patients (ticagrelor-based therapy ≈ 2,108; aspirin monotherapy ≈ 2,100) were included. Across the primary clinical endpoints, ticagrelor-based therapy showed no significant advantage over aspirin, with comparable rates of MACE (RR 1.05, 95% CI 0.78-1.41; p = 0.75; I² = 20%), all-cause mortality (RR 1.02, 95% CI 0.74-1.40; p = 0.93; I² = 0%), and major bleeding (RR 1.09, 95% CI 0.68-1.74; p = 0.73; I² = 51%). Similarly, no significant differences were observed for stroke (RR 1.10, 95% CI 0.70-1.75; p = 0.67; I² = 0%), myocardial infarction (RR 1.52, 95% CI 0.94-2.46; p = 0.09; I² = 27%), or repeat revascularization (RR 1.02, 95% CI 0.71-1.45; p = 0.93; I² = 7%). In contrast to the neutral clinical outcomes, ticagrelor-based therapy was associated with a significant reduction in saphenous vein graft (SVG) failure compared with aspirin monotherapy (RR 0.62, 95% CI 0.50-0.78; p < 0.0001; I² = 0%). Subgroup analysis revealed no meaningful differences between ticagrelor monotherapy and ticagrelor plus aspirin for major clinical events. Ticagrelor-based therapy did not reduce major clinical outcomes (MACE, mortality, MI, stroke, revascularization, or major bleeding) compared with aspirin after CABG, although it was associated with improved SVG patency. Routine use cannot be recommended; ticagrelor may be considered in selected high-risk patients. Further large, long-term trials are needed to determine whether patency benefits translate into improved clinical outcomes.