CYP2C19 genotype and platelet aggregation test-guided dual antiplatelet therapy after off-pump coronary artery bypass grafting: A retrospective cohort study

Haoyi Yao; Kaijie Qin; Yun Liu; Yi Yang; Jiaxi Zhu; Anqing Chen; Zhe Wang; Xiaofeng Ye; Mi Zhou; Haiqing Li; Jiapei Qiu; Qiang Zhao; Yunpeng Zhu

doi:10.3389/fcvm.2022.1023004

CYP2C19 genotype and platelet aggregation test-guided dual antiplatelet therapy after off-pump coronary artery bypass grafting: A retrospective cohort study

Front Cardiovasc Med. 2022 Dec 6:9:1023004. doi: 10.3389/fcvm.2022.1023004. eCollection 2022.

Authors

Haoyi Yao¹, Kaijie Qin¹, Yun Liu¹, Yi Yang¹, Jiaxi Zhu¹, Anqing Chen¹, Zhe Wang¹, Xiaofeng Ye¹, Mi Zhou¹, Haiqing Li¹, Jiapei Qiu¹, Qiang Zhao¹, Yunpeng Zhu¹

Affiliation

¹ Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Abstract

Background: Dual antiplatelet therapy (DAPT) is recommended in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). Clopidogrel is less effective among patients with loss-of-function (LoF) of CYP2C19 alleles, while ticagrelor has direct effects on P2Y₁₂ receptor. Whether a CYP2C19 genotype plus platelet aggregation test (PAgT)-guided DAPT after CABG could improve clinical outcomes remain uncertain.

Materials and methods: From August 2019 to December 2020, 1,134 consecutive patients who underwent OPCAB received DAPT for 1 year after surgery in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. According to the actual treatment they received in real-world, 382 (33.7%) of them received a traditional DAPT: aspirin 100 mg qd + clopidogrel 75 mg qd, no matter the CYP2C19 genotype and response in platelet aggregation test (PAgT). The other 752 (66.3%) patients received an individual DAPT based on CYP2C19 genotype and PAgT: aspirin 100 mg qd + clopidogrel 75 mg qd if CYP2C19 was extensive metabolizer, or moderate metabolizer but normal response in PAgT; aspirin 100 mg qd + ticagrelor 90 mg bid if CYP2C19 was poor metabolizer, or moderate metabolizer but no or low response in PAgT. One-year follow-up was achieved for all patients. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, and stroke. The safety outcome was thrombolysis in myocardial infarction (TIMI) criteria major bleeding.

Results: Compared with the traditional DAPT group, the risk of MACE in the individual DAPT group was significantly lower (5.5 vs. 9.2%, HR 0.583; 95% CI, 0.371-0.915; P = 0.019), mainly due to the decreased risk of MI (1.7 vs. 4.2%, HR 0.407; 95% CI, 0.196-0.846; P = 0.016). The risk of TIMI major bleeding events was similar between the two groups (5.3 vs. 6.0%, RR 0.883; 95% CI, 0.537-1.453; P = 0.626).

Conclusion: For patients who underwent OPCAB, individual DAPT (CYP2C19 genotype plus PAgT-guided strategy) was associated with a lower risk of MACE and a similar risk of major bleeding.

Keywords: CYP2C19 genotype; dual antiplatelet therapy (DAPT); major adverse cardiovascular events (MACE); major bleeding; off-pump coronary artery bypass grafting (OPCAB); platelet aggregation test (PAgT).