What is the recommended management for patients after Coronary Artery Bypass Grafting (CABG)?

From the Guidelines

The recommended management for patients after Coronary Artery Bypass Grafting (CABG) includes a comprehensive approach focusing on medication therapy, lifestyle modifications, and cardiac rehabilitation, with aspirin therapy initiated post-operatively as soon as there is no concern over bleeding, as recommended by the 2024 ESC guidelines 1.

Medication Therapy

• Aspirin 81-325 mg daily indefinitely is recommended for all patients after CABG, with consideration of dual antiplatelet therapy using clopidogrel 75 mg daily for 12 months in select patients, as supported by the 2016 ACC/AHA guideline 1.
• Statin therapy should be initiated or continued at high intensity (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) regardless of lipid levels, as recommended by the 2013 European Heart Journal article 1.
• Beta-blockers such as metoprolol 25-100 mg twice daily should be prescribed for all patients without contraindications, as recommended by the 2011 ACCF/AHA guideline 1.
• ACE inhibitors (like ramipril 2.5-10 mg daily) or ARBs are recommended for patients with reduced ejection fraction, diabetes, or hypertension, as supported by the 2013 European Heart Journal article 1.

Lifestyle Modifications

• Patients should follow a heart-healthy Mediterranean-style diet, as recommended by the 2013 European Heart Journal article 1.
• Engage in moderate-intensity aerobic exercise for 30 minutes at least 5 days per week once cleared by their surgeon, as recommended by the 2013 European Heart Journal article 1.
• Completely abstain from smoking, as recommended by the 2013 European Heart Journal article 1.
• Attend all follow-up appointments, as recommended by the 2013 European Heart Journal article 1.

Cardiac Rehabilitation

• Cardiac rehabilitation should begin within 2-4 weeks after discharge and continue for 12 weeks, including supervised exercise, nutritional counseling, and psychological support, as recommended by the 2011 ACCF/AHA guideline 1.
• Cardiac rehabilitation is recommended for all eligible patients after CABG, as supported by the 2011 ACCF/AHA guideline 1.

From the FDA Drug Label

In patients who stopped therapy more than five days prior to CABG the rates of major bleeding were similar (event rate 4. 4% clopidogrel bisulfate + aspirin; 5.3% placebo + aspirin). In patients who remained on therapy within five days of CABG, the major bleeding rate was 9.6% for clopidogrel bisulfate + aspirin, and 6. 3% for placebo + aspirin. Do not start ticagrelor in patients undergoing urgent coronary artery bypass graft surgery (CABG).

The recommended management for patients after Coronary Artery Bypass Grafting (CABG) includes:

• Discontinuing antiplatelet therapy, such as clopidogrel or ticagrelor, at least 5 days prior to CABG to reduce the risk of major bleeding.
• Avoiding the use of ticagrelor in patients undergoing urgent CABG.
• Managing bleeding without discontinuing antiplatelet therapy, if possible, as stopping therapy increases the risk of subsequent cardiovascular events 2, 3.

From the Research

Post-CABG Management

The management of patients after Coronary Artery Bypass Grafting (CABG) is crucial to prevent graft failure and reduce morbidity and mortality rates. The following are key aspects of post-CABG management:

• Medications: Statins and aspirin are essential medications that should be continued indefinitely unless contraindications exist 4. However, the use of these medications remains suboptimal, with only 67% of patients being prescribed a statin and 75% being prescribed aspirin 4.
• Antiplatelet and Anticoagulant Therapy: The use of dual antiplatelet therapy, such as clopidogrel or ticagrelor, in addition to aspirin, may have significant protective effects in patients undergoing off-pump CABG 5. However, the evidence for post-CABG anticoagulation is weak, and anticoagulation seems to be indicated only in post-CABG patients at high risk of future ischemic events 5.
• Aspirin Dosage: The optimal dose of aspirin for the prevention of graft occlusion in people undergoing coronary surgery is unclear, but high-dose aspirin (162-325mg once daily) may be superior to low-dose aspirin (75-100mg once daily) in suppressing platelet function 6.
• Cardiac Dysfunction: Cardiac dysfunction, including myocardial infarction, heart failure, and atrial fibrillation, is a common complication after CABG 7. Preoperative statin and aspirin therapy may help reduce the risk of post-CABG myocardial infarction, and other therapies, such as clopidogrel and prasugrel, may also be beneficial 7.
• Gaps in Care: There are gaps in the use of recommended medications after CABG, with lower anti-platelet and statin use associated with older age, freedom from angina, comorbid heart failure or hypertension, and not regularly visiting a cardiologist 8.

Key Considerations

Some key considerations in post-CABG management include:

• The importance of continuing statins and aspirin indefinitely unless contraindications exist 4
• The potential benefits of dual antiplatelet therapy in patients undergoing off-pump CABG 5
• The need for further research to evaluate the effectiveness of different dual antiplatelet regimens and anticoagulation therapy in post-CABG patients 5
• The importance of addressing gaps in care, including lower anti-platelet and statin use, to improve outcomes in post-CABG patients 8