**Author details**

*The Current Perspectives on Coronary Artery Bypass Grafting*

in addition to OAC should be used [1].

up to 36 months may be considered [1].

**5. Conclusion**

resistance.

any clinical benefit.

able on this subject.

to 6 months if concerns about ischemic risks are prevailing), and then dual therapy is to be considered (OAC and clopidogrel) up to 12 months [1]. Non-vitamin K oral anticoagulant (NOAC) should be considered instead of vitamin K antagonist (VKA). International normalized ratio (INR) is suggested to be in the lower part of the recommended target range, and time in therapeutic range should be maximized (i.e., >65–70%) when VKA is used [1, 71]. Using low dose (≤100 mg) of ASA is recommended and also routine use of proton pump inhibitors (PPIs) [1, 71]. Clopidogrel is the P2Y12 inhibitor of choice in such regimen of therapy; the use of prasugrel and ticagrelor should be avoided [1]. In a study of 377 patients who underwent drug-eluting stent implantation and had an indication for oral anticoagulation, prasugrel was evaluated as alternative to clopidogrel, and results showed an increased risk of bleeding in patients needing triple therapy [100]. Recent meta-analysis demonstrated that the use of ticagrelor as part of dual or triple therapy is associated with significantly higher rates of clinically relevant hemorrhagic complications than clopidogrel [101]. Latest review article on this subject points out already known stronger antiplatelet effect of ticagrelor and prasugrel, yet they are not used because of the increased risk, whether real or perceived, which has not been confirmed with large RCT in patients with ACS and atrial fibrillation [102]. In patients eligible for CABG surgery, DAPT should be avoided on the top of OAC and is not suggested in which antiplatelet agent

• There is no strong evidence based on RCTs or meta-analysis regarding duration and choice of antiplatelet agents after CABG, especially in setting of stable CAD.

• The 2017 ESC focused update guideline suggests insufficient evidence to generally recommend DAPT postoperatively to reduce graft occlusion in stable patients who underwent CABG, unless concomitant or prior indication overrides. In setting of ACS, combination of ASA with P2Y12 inhibitor is recommended up to 12 months after CABG, but the choice between ASA and which P2Y12 inhibitor to use is not clearly defined. In patients perceived at high ischemic risk with prior MI and CABG who have tolerated DAPT without bleeding complications, treatment with DAPT for longer than 12 months and

• There is no clear evidence of aspirin resistance in CABG patients and effect on their clinical outcome. Also, there is no uniform data regarding addition of clopidogrel to ASA in reducing the incidence of CABG-related aspirin

• Available data suggests that the incidence of late MACEs was higher in the HPR group after clopidogrel administration post CABG, and also higher prevalence of HPR was shown in CAD patients treated with clopidogrel than patients treated with ticagrelor or prasugrel. Positive effect of adjusting standard clopidogrel treatment based on platelet function testing was shown; however, personalized therapy is not recommended because no large RCT demonstrated

• Ticagrelor and prasugrel have a low occurrence of HPR, and platelet function testing is not recommended; in addition there are no large RCT studies avail-

**56**

Ivana Sopek Merkas1 \*, Nenad Lakusic1,2,3, Krunoslav Fuckar1,2, Dusko Cerovec1,2 and Kristina Maric Besic4,5

1 Special Hospital for Medical Rehabilitation Krapinske Toplice, Krapinske Toplice, Croatia

2 Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

3 Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

4 University Hospital Centre Zagreb, Zagreb, Croatia

5 Faculty of Medicine Zagreb, University of Zagreb, Zagreb, Croatia

\*Address all correspondence to: ivana.sopek92@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
