From the Guidelines
Management of stroke post CABG requires prompt neurological assessment, immediate neuroimaging, and tailored secondary prevention strategies based on the underlying mechanism, with a focus on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, provides guidance on the management of patients with acute coronary syndromes, including those who have undergone CABG.
Initial Management
Initial management includes:
- Immediate neuroimaging with CT or MRI to distinguish between ischemic and hemorrhagic stroke
- Intravenous thrombolysis with alteplase (0.9 mg/kg, maximum 90 mg, with 10% given as bolus and remainder over 60 minutes) for ischemic stroke, if detected within 4.5 hours and without contraindications, though recent cardiac surgery presents relative contraindications
- Mechanical thrombectomy for large vessel occlusions within 24 hours of symptom onset
Antiplatelet Therapy
Antiplatelet therapy typically includes:
- Aspirin (81-325 mg daily)
- Clopidogrel (75 mg daily) depending on stent placement and bleeding risk The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline, 1, recommends the use of oral P2Y12 inhibitors in ACS for reducing MACE, but with increased risk of bleeding.
Blood Pressure Management
Blood pressure management targets systolic 140-180 mmHg in the acute phase, with more aggressive control after 24-48 hours.
Statin Therapy
Statins should be continued or initiated (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily), as they have been shown to reduce the risk of MACE and improve survival, 1.
Post-Stroke Care
Post-stroke care includes:
- Swallowing assessment before oral intake
- Early mobilization
- Prevention of complications (DVT prophylaxis with intermittent pneumatic compression and possibly low-dose anticoagulation when safe)
- Cardiac monitoring for at least 72 hours to detect atrial fibrillation
Secondary Prevention
Secondary prevention strategies should be tailored to the underlying mechanism of the stroke, which may include embolization of atherosclerotic debris during aortic manipulation, hypoperfusion during bypass, or postoperative atrial fibrillation, 1. The 2024 ESC guidelines, 1, recommend low-dose aspirin lifelong in patients undergoing CABG, and the use of DAPT with a P2Y12 receptor inhibitor compared with aspirin monotherapy for higher graft patency rates after CABG.
From the Research
Management of Stroke Post Coronary Artery Bypass Grafting (CABG)
The management of stroke post CABG is a complex process that involves various aspects of care, including rehabilitation, medical management, and surgical interventions.
- Rehabilitation: Rehabilitation is an essential aspect of the continuum of care in stroke, and it plays a crucial role in the management of stroke post CABG 2. The goal of rehabilitation is to help patients recover from the physical and cognitive impairments caused by the stroke.
- Medical Management: Medical management of stroke post CABG involves the use of various medications to prevent further strokes, manage risk factors, and treat complications 3.
- Surgical Interventions: Surgical interventions, such as carotid endoarterectomy (CEA), may be necessary to manage carotid artery disease, which is a known risk factor for stroke post CABG 4, 5.
Risk Factors and Predictors of Stroke Post CABG
Several risk factors and predictors of stroke post CABG have been identified, including:
- Preoperative serum creatinine levels: High preoperative serum creatinine levels have been associated with an increased risk of mortality and stroke post CABG 6.
- Postoperative occurrence of renal failure: Postoperative renal failure has been associated with an increased risk of mortality and stroke post CABG 6.
- Cerebrovascular atherosclerotic disease: Cerebrovascular atherosclerotic disease is a known risk factor for stroke post CABG, and evaluation of cerebral artery risk before off-pump CABG is essential to avoid perioperative stroke 5.
Outcomes and Prognosis
The outcomes and prognosis of patients with stroke post CABG are generally poor, with high mortality rates and significant morbidity 6. However, with advances in medical management and surgical interventions, the outcomes and prognosis of these patients can be improved.
- Mortality rates: The mortality rates for patients with stroke post CABG are significantly higher than those for patients without stroke, with a median survival time of 6.7 years 6.
- Recovery and rehabilitation: Recovery and rehabilitation are essential aspects of the management of stroke post CABG, and they can help improve the outcomes and prognosis of these patients 2.