From the Guidelines
The optimal medical management for a patient with chest pain awaiting CABG includes a comprehensive regimen of antianginal medications, starting with aspirin 81mg daily, a high-intensity statin, and beta-blockers. The management strategy should prioritize reducing myocardial oxygen demand, improving coronary blood flow, stabilizing atherosclerotic plaques, and preventing thrombosis. Key components of this regimen include:
- Aspirin 81mg daily, continued until surgery 1
- A high-intensity statin like atorvastatin 40-80mg daily 1
- Beta-blockers such as metoprolol 25-100mg twice daily, titrated to heart rate 50-60 bpm 1
- Sublingual nitroglycerin 0.4mg for acute chest pain episodes, with instructions to take one tablet every 5 minutes for up to three doses and seek emergency care if pain persists 1
- Long-acting nitrates like isosorbide mononitrate 30-60mg daily and calcium channel blockers such as amlodipine 5-10mg daily if beta-blockers are contraindicated or insufficient 1
- Blood pressure should be maintained below 130/80 mmHg, and diabetes should be controlled with target HbA1c below 7% 1 This approach is supported by the most recent guidelines, including the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. Patients should also be advised to restrict physical activity, maintain a heart-healthy diet, and immediately report worsening symptoms, as these measures collectively reduce the risk of adverse cardiac events while awaiting definitive surgical intervention 1.
From the FDA Drug Label
The CURE study included 12,562 patients with ACS without ST-elevation (UA or NSTEMI) and presenting within 24 hours of onset of the most recent episode of chest pain or symptoms consistent with ischemia Patients were required to have either ECG changes compatible with new ischemia (without ST-elevation) or elevated cardiac enzymes or troponin I or T to at least twice the upper limit of normal. Patients were randomized to receive clopidogrel (300 mg loading dose followed by 75 mg once daily) or placebo, and were treated for up to one year Patients also received aspirin (75 to 325 mg once daily) and other standard therapies such as heparin.
The optimal medical management for a patient with chest pain scheduled for Coronary Artery Bypass Grafting (CABG) in the meantime is to administer clopidogrel (300 mg loading dose followed by 75 mg once daily) and aspirin (75 to 325 mg once daily), along with other standard therapies such as heparin.
- Key points:
- Administer clopidogrel and aspirin as soon as possible.
- Use heparin as part of the standard therapy.
- Continue treatment until CABG surgery.
- Monitor patient closely for any changes in condition. 2
From the Research
Optimal Medical Management
For a patient with chest pain scheduled for Coronary Artery Bypass Grafting (CABG), the optimal medical management in the meantime includes:
- Aspirin, unless contraindicated, as it is recommended for all patients with suspected acute coronary syndrome (ACS) 3
- Addition of a second antiplatelet, such as clopidogrel, ticagrelor, or prasugrel, for most patients 3
- Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 3
- Proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher risk of gastrointestinal bleeding 3
- Statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen as part of the medical therapy 3
Antiplatelet Therapy
The use of aspirin in combination with clopidogrel has been shown to be beneficial in patients with acute coronary syndromes, including those undergoing CABG 4. The optimal dose of aspirin when used alone or in combination with clopidogrel is between 75 and 100 mg daily, as higher doses increase the risk of bleeding without additional efficacy 5.
Management of Bleeding Risk
The risk of bleeding should be carefully managed, particularly in patients undergoing CABG. The use of clopidogrel plus aspirin has been shown to increase the risk of major bleeding, but the benefits of this combination outweigh the risks in most patients 4, 6.
Timing of CABG
Ideally, CABG should be delayed for 3 to 7 days after admission, unless the patient has cardiogenic shock, life-threatening arrhythmias, three-vessel disease, or other complications 3.