TACSI Trial Challenges Dual Antiplatelet Therapy After CABG, Shows No Benefit Over Aspirin Alone

Key Insights

• The TACSI trial of 2,201 patients found dual antiplatelet therapy with ticagrelor plus aspirin after CABG for acute coronary syndrome provided no additional cardiovascular benefit compared to aspirin alone at one year.
• Major bleeding events were significantly higher in the dual therapy group (4.9%) compared to aspirin alone (2.0%), while primary cardiovascular outcomes remained similar at approximately 5% for both groups.
• The findings challenge current international guidelines recommending dual antiplatelet therapy after CABG and suggest aspirin monotherapy may be the preferred approach for these patients.

A major Nordic trial has challenged the current standard of care for patients undergoing coronary artery bypass graft (CABG) surgery, finding that dual antiplatelet therapy offers no cardiovascular benefit over aspirin alone while significantly increasing bleeding risk.

The TACSI trial, published simultaneously in The New England Journal of Medicine and presented at ESC Congress 2025, compared ticagrelor plus aspirin versus aspirin monotherapy in 2,201 patients who underwent CABG for acute coronary syndrome across 22 Nordic heart surgery units.

No Cardiovascular Benefit Observed

The study's primary composite endpoint of death, myocardial infarction, stroke, or repeat revascularization at one year occurred in 4.8% of patients receiving dual therapy compared to 4.6% receiving aspirin alone. This minimal difference was not statistically significant, indicating no meaningful cardiovascular benefit from the addition of ticagrelor.

"Our 12-month data do not support the use of dual antiplatelet therapy over aspirin alone in ACS patients after CABG, given the lack of improvement in major adverse cardiac events and the increased risk of major bleeding," said Principal Investigator Anders Jeppsson, professor in cardiothoracic surgery at the University of Gothenburg and senior consultant at Sahlgrenska University Hospital.

Bleeding Risk Substantially Higher

The safety profile strongly favored aspirin monotherapy. Major bleeding occurred in 4.9% of patients on dual therapy compared to just 2.0% on aspirin alone. When bleeding events were included in a net adverse clinical events analysis, the dual therapy group experienced complications in 9.1% of patients versus 6.4% in the aspirin-only group.

Study Design and Patient Population

The randomized controlled trial enrolled patients with a mean age of 66 years, with women comprising 14.4% of the study population. Participants were randomly assigned to receive either ticagrelor and aspirin (1,104 patients) or aspirin alone (1,097 patients) following CABG surgery for acute coronary syndrome.

Implications for Clinical Practice

These findings directly challenge current international guidelines that recommend dual antiplatelet therapy for patients undergoing CABG for acute coronary syndrome. The results suggest that the bleeding risks associated with dual therapy may outweigh any potential cardiovascular benefits in this patient population.

Complementary Evidence from TOP-CABG

Supporting evidence came from the TOP-CABG trial, also presented at ESC Congress 2025, which examined de-escalated dual antiplatelet therapy strategies in over 2,000 post-CABG patients. The study found that reducing dual therapy duration from 12 months to 3 months followed by aspirin alone demonstrated noninferiority for graft occlusion (10.79% vs. 11.19%) while reducing clinically relevant bleeding events (8.26% vs. 13.19%).

The researchers acknowledged that longer-term follow-up beyond 12 months will be necessary to fully understand the implications of these antiplatelet strategies, but the current evidence suggests a fundamental reassessment of post-CABG antiplatelet therapy may be warranted.