Optimal antiplatelet therapy in patients after coronary artery bypass grafting.

Prior treatment

• Postoperative and prior randomization exclusion criteria: 1. Perioperative cardiogenic shock
• Intraoperative death or death prior randomization
• Myocardial infarction within 12-24 hours following CABG or prior randomization
• Ischemic or hemorrhagic stroke within 12-24 hours following CABG or prior randomization
• Atrial Fibrillation prior randomization
  • Single vessel CABG

Other illness

• Active malignant disease or history of malignancy within the past 5 years
• Planned additional cardiac or non-cardiac surgery within 12 months
• Non-cardiac co-morbidity with life expectancy less than 12 months
• History of any bleeding complications due to the use of DAPT
• History of intracranial bleeding
• History of gastro-intestinal bleeding
• Patients with recent acute coronary syndrome (ACS) (<12 months)

Lab values

• Severe impaired renal function (eGFR <40ml/min/1.73 m2).
• Gastro-intestinal bleeding prior randomization
  • Patients with preoperative atrial fibrillation
  • Dialysis
  • Thrombocytopenia (platelet count < 100 000 platelets/ul)
  • Anemia (Hemoglobin level < 10 g/dL)
  • Severe liver failure Child-Pugh classification >4
  • Known, active infections with HIV, HBV, HCV, tuberculosis

Other

• Baseline (preoperative) exclusion criteria: 1. Cardiogenic shock
• Indication for DAPT (e.g. recent PCI or ACS or recent stents of peripheral arteries)
• Indication for oral anticoagulant treatment
• Indications for the use of methotrexate at a dose of 15 mg/week or more
• Any contraindication for prasugrel or ASA
• Pregnancy or breastfeeding
• Lack of compliance with the use of a highly effective method of birth control
• Planned coronary endarterectomy
• Any postoperative complication that may increase patients’ risk with DAPT

• Age >18 years
• Primary isolated CABG patients with stable coronary artery disease (chronic coronary syndrome) planned for at least 2 grafts. Coronary artery disease will be defined as a stenosis ≥ 70% based on coronary angiography, a FFR value ≤ 0.80 or iFr value ≤0.89; a left main diameter stenosis ≥ 50%, left main IVUS MLA value ≤ 6 mm2, or equivalent OCT measurements will also be considered.
• Ability to comply with all study procedures and follow-up procedures
• Signed Informed Consent to participate in the study.
• Operative inclusion criteria:  1. Intraoperative graft evaluation using transit time flow measurement in all grafts, normal flow in any graft is defined as mean graft flow > 15 mL/min with Pulsatility Index < 5
• Left anterior descending artery grafted with internal thoracic artery
• No intraoperative decision for hybrid revascularization due to incomplete revascularization (Percutaneous coronary intervention (PCI) of the ungrafted vessel)
• No endarterectomy of the grafted vessel performed
• Patient did not have any additional unplanned procedure (Ex. LAAC, Ablation, valve intervention, aortic intervention)