Research Summary

Ticagrelor Plus Aspirin After CABG for ACS Shows No Added Benefit in Nordic Trial

Edited by:
Kate Young

Key Highlights

  • Dual antiplatelet therapy with ticagrelor plus aspirin did not reduce death, myocardial infarctioon, stroke, or repeat revascularization at 1 year.
  • Major bleeding occurred more frequently with ticagrelor plus aspirin.
  • Net adverse clinical events were significantly higher with dual therapy.

A new multinational, registry-based randomized clinical trial published in The New England Journal of Medicine assessed whether combining ticagrelor with aspirin improves clinical outcomes after coronary artery bypass grafting (CABG) performed for acute coronary syndrome (ACS). Despite guideline recommendations supporting dual antiplatelet therapy (DAPT) in this population, evidence has been limited and largely extrapolated from non-surgical cohorts. The TACSI trial provides the largest direct evaluation to date of postoperative DAPT in ACS-related CABG.

The TACSI trial enrolled 2201 adults at 22 cardiothoracic centers across Denmark, Finland, Iceland, Norway, and Sweden. Patients with ACS who had undergone isolated CABG within the previous 3–14 days were randomized 1:1 to ticagrelor (90 mg twice daily) plus aspirin or aspirin alone for 1 year. Outcomes were ascertained using national health registries and structured follow-up. The primary endpoint was a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 1 year. The key secondary endpoint was net adverse clinical events (NACE), defined as the primary endpoint or major bleeding requiring hospitalization. Safety outcomes included major bleeding, severe dyspnea, and new-onset renal failure.

Study Findings

A total of 1104 patients received ticagrelor plus aspirin and 1097 received aspirin alone. The mean age was 66 years, and 14.4% of participants were women.

Primary-outcome events occurred in 4.8% of the ticagrelor-plus-aspirin group and 4.6% of the aspirin-alone group (hazard ratio [HR], 1.06; 95% CI, 0.72–1.56; P = .77). NACE was more common with dual therapy (9.1% vs 6.4%; HR, 1.45; 95% CI, 1.07–1.97).

Major bleeding occurred in 4.9% of patients in the ticagrelor group compared with 2.0% in the aspirin-only arm (HR, 2.50; 95% CI, 1.52–4.11). Severe dyspnea, another known ticagrelor-related adverse event, was also more frequent with dual therapy (18.2% vs 6.4%).

Treatment adherence differed between groups: 64.1% of patients assigned ticagrelor remained adherent at 1 year compared with 92.3% in the aspirin-alone group.

Clinical Implications

The study demonstrates that adding ticagrelor to aspirin after CABG for ACS does not improve major cardiovascular outcomes at 1 year but does increase major bleeding. The authors note that the lower-than-expected event rates and substantial nonadherence to ticagrelor may have affected results, though registry data and follow-up completeness were strong. Nonetheless, the findings directly address a key evidence gap and provide an important counterbalance to existing guideline recommendations derived from non-CABG data.

Expert Commentary

“In this trial, the addition of ticagrelor to aspirin for the prevention of death, myocardial infarction, stroke, or repeat revascularization during the first year after CABG for an acute coronary syndrome was not superior to aspirin alone,” the researchers concluded.

Reference
Jeppsson A, James S, Moller CH, et al. Ticagrelor and aspirin or aspirin alone after coronary surgery for acute coronary syndrome. N Engl J Med. 2025;393:2313-2323. doi:10.1056/NEJMoa2508026.