Study title: TOP-CABG trial – De-escalation of dual antiplatelet therapy provides benefits in patients after coronary artery bypass grafting

Congress: ESC 2025

Link: https://www.escardio.org/The-ESC/Press-Office/Press-releases/De-escalation-of-dual-antiplatelet-therapy-provides-benefits-in-patients-after-coronary-artery-bypass-grafting

Prepared by: Dr. Murat Karaçam

Introduction
One of the major challenges after coronary artery bypass grafting (CABG) is occlusion of saphenous vein grafts (SVG). To improve graft patency, dual antiplatelet therapy (DAPT) is generally recommended for 12 months. However, prolonged DAPT increases the risk of major bleeding complications, particularly in patients at high bleeding risk. Thus, the safety of shortening the duration of DAPT remains a critical clinical question.
Objective
The TOP-CABG trial aimed to investigate whether switching to aspirin monotherapy after 3 months of DAPT is non-inferior to 12 months of DAPT in terms of graft patency, while also evaluating bleeding outcomes.

Methods
A total of 2,290 patients undergoing first-time CABG with at least one SVG graft were enrolled.

• Randomization:
• De-escalation arm: Ticagrelor + aspirin for 3 months › followed by aspirin monotherapy for 9 months
• Control arm: Ticagrelor + aspirin for 12 months
• Primary efficacy endpoint: SVG occlusion within the first postoperative year
• Primary safety endpoint: Major bleeding (BARC ?2) within the first postoperative year

Results

• SVG occlusion rates were similar between the two groups (10.8% vs. 11.2%; difference -0.3 percentage points; p=0.008 for non-inferiority).
• Major bleeding was significantly lower in the de-escalation arm (8.3% vs. 13.2%; HR 0.62; p<0.001).
• No significant differences were observed in secondary outcomes (death, MI, repeat revascularization).

Conclusion
Switching to aspirin monotherapy after 3 months of DAPT provided comparable SVG patency while significantly reducing bleeding risk compared with 12 months of DAPT.

Commentary
TOP-CABG is an important trial that challenges the conventional 12-month DAPT strategy after CABG. Since SVGs, commonly used in CABG, carry a substantial risk of early and late occlusion, strategies to maintain graft patency are essential. This study demonstrates that short-term DAPT offers a safe and effective alternative to prolonged DAPT, especially in patients at high bleeding risk. Beyond its clinical implications, the findings also provide key insights that may inform future guideline recommendations on the use of shorter DAPT regimens.