Why should a patient who has undergone coronary artery bypass grafting (CABG) avoid taking steroids like prednisone (corticosteroid)?

From the Guidelines

Patients who have undergone coronary artery bypass grafting (CABG) should generally avoid taking corticosteroids like prednisone whenever possible. These medications can interfere with the healing process after cardiac surgery and may increase the risk of complications. Corticosteroids can impair wound healing by suppressing collagen formation and reducing the strength of surgical incisions, which is particularly concerning for sternal wounds following CABG 1. They can also promote fluid retention and sodium retention, potentially worsening heart failure symptoms or increasing blood pressure in post-CABG patients. Additionally, corticosteroids may increase the risk of infection due to their immunosuppressive effects, which is especially problematic after major surgery when patients are already vulnerable to infections.

Some guidelines suggest the use of corticosteroids in patients undergoing cardiopulmonary bypass surgery, but this is based on a conditional recommendation with moderate quality of evidence 1. However, considering the potential risks associated with corticosteroid use in post-CABG patients, such as impaired wound healing, increased risk of infection, and potential for exacerbating heart failure or hypertension, it is crucial to weigh these risks against any potential benefits. If a patient has a condition requiring corticosteroid therapy, their cardiologist and primary physician should carefully consider the risks and benefits, potentially using the lowest effective dose for the shortest duration possible.

Key considerations in the management of post-CABG patients include:

• Minimizing the risk of complications such as infection, heart failure, and hypertension
• Promoting optimal wound healing and reducing the risk of sternal wound complications
• Carefully managing medications that may interfere with the healing process or increase the risk of complications
• Close monitoring and follow-up to quickly identify and address any potential issues that may arise.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, suppress the immune system and increase the risk of infection with any pathogen, including viral, bacterial, fungal, protozoan, or helminthic pathogens Corticosteroids can: • Reduce resistance to new infections • Exacerbate existing infections • Increase the risk of disseminated infections • Increase the risk of reactivation or exacerbation of latent infections • Mask some signs of infection

The patient who has undergone coronary artery bypass grafting (CABG) should avoid taking steroids like prednisone because corticosteroids suppress the immune system and increase the risk of infection. After CABG, the patient is already at a higher risk of infection, and taking corticosteroids could further increase this risk, potentially leading to severe or fatal complications 2. Additionally, corticosteroids can mask some signs of infection, making it more difficult to diagnose and treat infections promptly 2.

• Key points to consider:
  • Increased risk of infection
  • Suppression of the immune system
  • Potential for severe or fatal complications
  • Masking of infection signs

It is essential to weigh the benefits and risks of corticosteroid therapy in patients who have undergone CABG, and alternative treatments should be considered when possible 2.

From the Research

Reasons to Avoid Steroids after Coronary Bypass

• The use of perioperative corticosteroids in patients undergoing coronary artery bypass grafting (CABG) may result in little to no difference in all-cause mortality, but could increase the risk of myocardial complications 3.
• Corticosteroids may reduce the risk of pulmonary complications and infectious complications, but the evidence is of low certainty 3, 4.
• The administration of corticosteroids after CABG may also lead to an increased risk of atrial fibrillation, although some studies suggest a reduced incidence 4, 5.
• The efficacy and safety profile of corticosteroids in cardiac surgery remains uncertain, with conflicting results from different studies 6, 4.

Potential Risks and Complications

• Myocardial complications: Corticosteroids may increase the risk of myocardial complications, such as myocardial infarction or cardiac arrhythmias 3, 4.
• Pulmonary complications: While corticosteroids may reduce the risk of pulmonary complications, the evidence is of low certainty 3, 4.
• Infectious complications: Corticosteroids may reduce the risk of infectious complications, but the evidence is of low certainty 3, 4.
• Atrial fibrillation: The administration of corticosteroids after CABG may lead to an increased risk of atrial fibrillation, although some studies suggest a reduced incidence 4, 5.

Clinical Implications

• The use of corticosteroids in patients undergoing CABG should be carefully considered, taking into account the potential risks and benefits 3, 4.
• Further research is needed to fully understand the effects of corticosteroids in cardiac surgery and to determine the optimal treatment strategy 3, 4.
• Clinicians should be aware of the potential risks and complications associated with corticosteroid use in patients undergoing CABG and closely monitor patients for adverse effects 3, 4.