Patient-centred anti-platelet therapy following coronary artery bypass graft surgery

While lifelong aspirin mono-therapy remains the standard of care following coronary artery bypass graft surgery (CABG), the optimal antiplatelet strategy remains a subject of ongoing debate. The evidence argues against a 'one-size-fits-all' strategy and supports a patient-centred approach. Antiplatelet treatment decisions should incorporate bleeding risk which is often multifactorial and necessitates careful individualised evaluation based on patient characteristics and procedural factors. Conduit selection should also be considered as graft failure following CABG remains an important problem and varies according to conduit type, highlighting the critical role of antiplatelet therapy. Saphenous vein grafts are particularly susceptible to early thrombosis and late atherosclerotic degeneration, making optimisation of antiplatelet therapy especially relevant for preserving vein graft patency, whereas its impact on arterial grafts is less well defined. Current guideline recommendations are largely extrapolated from studies involving patients with acute or chronic coronary syndromes treated with percutaneous intervention or medical therapy. Clinical presentation is also a key determinant of antiplatelet strategy. Although current guidelines support resumption of dual antiplatelet therapy (DAPT) after CABG in patients with acute coronary syndromes (ACS), these recommendations are largely inherited from CABG subgroups of broader ACS trials rather than dedicated CABG randomised studies, and recent CABG-specific evidence has challenged the routine use of ticagrelor-based DAPT in this setting. DAPT in chronic coronary syndromes may be considered only in selected patients at low bleeding risk. Although, observational and randomised data suggest that DAPT can improve vein graft patency, but this has not consistently translated into short-term clinical benefit and is offset by increased bleeding risk. In fact, emerging evidence suggests shorter or de-escalated DAPT strategies may offer a more favourable balance between graft protection and bleeding.