Hot Line 10: NEWTON-CABG CardioLink-5, TACSI, TOP-CABG, OPINION
01 Sep 2025
Hot Line ESC Congress 2025 Hot Line 10 mainly focused on aspects of heart surgery – coronary artery bypass grafting (CABG) and surgical left atrial appendage occlusion (SLAAO).
Professor Subodh Verma (St. Michael’s Hospital - Toronto, Canada) began the session by presenting results from the international NEWTON-CABG CardioLink-5 trial, which investigated whether intensive low-density lipoprotein cholesterol (LDL-C) lowering with evolocumab could improve early saphenous vein graft (SVG) failure after CABG. A total of 782 patients who underwent CABG surgery with at least two SVGs and who were receiving moderate-to-high-intensity statin therapy were randomised postoperatively (3–21 days after CABG) to subcutaneous evolocumab 140 mg or placebo every 2 weeks. The primary endpoint was the proportion of SVGs with ≥50% occlusion at 24 months, which was not significantly different between the groups (21.7% with evolocumab vs. 19.7% with placebo; p=0.44). The median LDL-C level was 1.9 mmol/l at baseline and evolocumab achieved a mean 48.4% placebo-adjusted reduction at 24 months. Prof. Verma concluded: “Our findings suggest that further LDL-C lowering does not affect the pathophysiological mechanisms of early SVG failure. Rather, remodelling, thrombotic and/or inflammatory processes may be responsible and further research is needed to develop novel approaches to reduce the current high rates of SVG disease.”
As explained by Professor Anders Jeppsson (Sahlgrenska University Hospital - Gothenburg, Sweden), the registry-based TACSI trial investigated 12 months of dual antiplatelet therapy (DAPT) with ticagrelor and aspirin compared with aspirin alone in 2,201 patients with acute coronary syndrome (ACS) undergoing CABG. The primary efficacy endpoint of all-cause death, myocardial infarction, stroke or new coronary revascularisation at 12 months occurred in a similar proportion of patients in each group: 4.8% of patients in the DAPT group and 4.6% in the aspirin only group (hazard ratio [HR] 1.09; 95% CI 0.74 to 1.60; log rank p=0.77). Of note, major bleeding was more frequent with DAPT than aspirin alone (4.9% vs. 2.0%; HR 2.50; 95% CI 1.52 to 4.11). Concluding, Prof. Jeppsson said: “Our 12-month data do not support the use of DAPT over aspirin alone in ACS patients after CABG given the lack of improvement in cardiovascular (CV) outcomes and the increased risk of major bleeding. However, further long-term follow-up is needed.”
Another study investigating optimal antiplatelet therapy was the TOP-CABG trial, presented by Doctor Xin Yuan (State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases - Beijing, China). In this trial, 2,290 patients undergoing their first planned CABG with at least one SVG were randomised to de-escalated DAPT (ticagrelor 90 mg twice daily plus aspirin 100 mg once daily for 3 months, then placebo twice daily plus aspirin 100 mg once daily for 9 months) or to DAPT (ticagrelor 90 mg twice daily plus aspirin 100 mg once daily for 1 year). Noninferiority was demonstrated for the primary efficacy endpoint of 100% occlusion of the SVG within 1 year, which occurred in 10.79% of patients’ SVGs in the de-escalated DAPT group and 11.19% in the DAPT group (difference –0.31%; p=0.008). However, clinically relevant bleeding was less frequent with de-escalated DAPT vs. DAPT (8.26% vs. 13.19%; HR 0.62; 95% CI 0.48 to 0.81; p<0.001). Dr. Yuan concluded: “A de-escalation strategy offered a better balance between graft patency protection and bleeding risk than DAPT. These findings may help to inform future guidelines regarding the benefits of a shorter period of DAPT during the early phase after CABG.”
Finally, Professor Yang Wang (State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases - Beijing, China) discussed the findings of the OPINION trial, which investigated SLAAO vs. no SLAAO in 2,118 high-risk patients after valvular surgery without atrial fibrillation. The primary endpoint of ischaemic stroke, transient ischaemic attack or cardiovascular mortality at 1 year was not significantly different between the groups, occurring in 6.9% of patients in the SLAAO group and 8.2% of patients in the control group (HR 0.83; 95% CI 0.61 to 1.14; p=0.25). There was no significant difference in bleeding events. Summarising the results, first author, Doctor Xin Yuan (State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases - Beijing, China) said: “The trial found no significant benefit of routine SLAAO in the overall study population. We have planned further analyses in high-risk subgroups and, given the divergence in primary endpoint event curves observed after 6 months, we are extending follow-up to 3 years.”
