Safety and efficacy of ticagrelor plus aspirin vs. aspirin monotherapy in patients undergoing coronary artery bypass grafting: A meta-analysis with trial sequential analysis.

Optimal antiplatelet therapy after coronary artery bypass grafting (CABG) remains debated. While aspirin is standard, the benefit of adding ticagrelor, a P2Y₁₂ inhibitor with distinct pharmacological properties, is unclear. We compared the efficacy and safety of ticagrelor plus aspirin versus aspirin alone in patients undergoing CABG. We systematically searched major databases for randomized controlled trials and observational studies comparing ticagrelor plus aspirin with aspirin alone in post-CABG patients. The primary efficacy endpoint was trial-defined MACE. Secondary efficacy endpoints included all-cause mortality, cardiovascular death, stroke, MI, revascularization, and saphenous vein graft failure. The primary safety endpoint was major bleeding. A total of seven studies (five randomized controlled trials (RCTs) and one observational study) were included, enrolling 11,893 patients post-CABG, primarily for acute coronary syndrome or stable angina. The majority of studies had a follow-up duration of one year. Ticagrelor plus aspirin significantly reduced the risk of trial-defined MACE (RR 0.61, 95% CI 0.45–0.84; I2 = 0%) and stroke (RR 0.49, 95% CI 0.29–0.82; I2 = 11.5%), but did not reduce all-cause mortality, myocardial infarction, or cardiovascular death. However, it significantly increased the risk of major bleeding (RR 1.70, 95% CI 1.06–2.71; I2 = 42%), while minor bleeding showed no difference (RR 2.38, 95% CI 0.88, 6.43; I2 = 39%). In a sensitivity analysis restricted to RCTs alone (n = 4,905), the reduction in trial-defined MACE remained significant (RR 0.61, 95% CI 0.45–0.84), while the reduction in stroke (RR 0.74, 95% CI 0.35–1.56) and the increase in major bleeding (RR 1.82, 95% CI 0.77–4.34) were no longer statistically significant. In patients undergoing CABG, the addition of ticagrelor to aspirin reduces trial-defined MACE and stroke compared with aspirin alone, but increases the risk of major bleeding without a mortality benefit. These findings support a personalized, risk-stratified approach to antiplatelet therapy, though they are limited by the number and heterogeneity of available studies. Further trials are warranted to define the optimal antiplatelet regimen in this population.Clinical Trial Registration Number: Not applicable.