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

Comprehensive Management of Coronary Artery Bypass Grafting (CABG)

The recommended management for CABG includes preoperative aspirin administration, postoperative initiation of aspirin within 6 hours, statin therapy for all patients, beta-blocker administration before and after surgery, and glycemic control with target blood glucose ≤180 mg/dL. 1

Perioperative Medication Management

Antiplatelet Therapy

• Preoperative Management:

  • Aspirin (100-325 mg daily) should be administered preoperatively 1
  • For elective CABG: Discontinue clopidogrel and ticagrelor at least 5 days before surgery, prasugrel for at least 7 days 1
  • For urgent CABG: Discontinue clopidogrel and ticagrelor for at least 24 hours 1
  • Discontinue glycoprotein IIb/IIIa inhibitors: eptifibatide/tirofiban 2-4 hours before surgery, abciximab 12 hours before 1

• Postoperative Management:

  • If aspirin was not initiated preoperatively, start within 6 hours postoperatively and continue indefinitely 1
  • Single antiplatelet therapy with aspirin is the standard for most patients after CABG 1
  • Dual antiplatelet therapy (DAPT) may be considered in selected patients at greater risk of graft occlusion and low bleeding risk, though evidence is limited 1, 2

Lipid Management

• All patients should receive statin therapy unless contraindicated (Class I, Level A) 1
• Target LDL-cholesterol <100 mg/dL with at least 30% reduction from baseline 1
• Do not discontinue statin therapy before or after CABG 1

Beta-Blockers

• Administer for at least 24 hours before CABG 1
• Reinstitute as soon as possible after CABG 1
• Prescribe to all patients without contraindications at hospital discharge 1
• Particularly beneficial in patients with LVEF >30% 1

Glycemic Control

• Use continuous intravenous insulin to achieve and maintain postoperative blood glucose ≤180 mg/dL while avoiding hypoglycemia 1
• This reduces deep sternal wound infections and other adverse events 1

Anesthetic Considerations

• Anesthetic management should be directed toward early postoperative extubation and accelerated recovery 1
• Volatile anesthetic-based regimens facilitate early extubation and reduce patient recall 1
• Intraoperative transesophageal echocardiography is recommended for:
  • Evaluation of acute, persistent hemodynamic disturbances 1
  • Patients undergoing concomitant valvular surgery 1
  • Monitoring hemodynamic status and ventricular function 1

Surgical Considerations

Graft Selection

• Left internal mammary artery (LIMA) should be used to bypass the left anterior descending (LAD) artery whenever possible 1

Hybrid Revascularization

• Hybrid coronary revascularization (LIMA-to-LAD grafting plus PCI of non-LAD vessels) is reasonable in patients with:
  • Heavily calcified proximal aorta or poor target vessels for CABG
  • Lack of suitable graft conduits
  • Unfavorable LAD for PCI 1

Emergency CABG Indications

Emergency CABG is recommended for:

• Failed primary PCI with persistent ischemia and suitable coronary anatomy 1
• Mechanical complications of MI (ventricular septal rupture, mitral valve insufficiency, free wall rupture) 1
• Cardiogenic shock with suitable anatomy 1
• Life-threatening ventricular arrhythmias with left main stenosis ≥50% and/or 3-vessel CAD 1

Post-Discharge Management

Medication Adherence

• Long-term use of secondary prevention medications is often suboptimal despite clear guideline recommendations 3, 4
• Only 52-67% of patients are prescribed both aspirin and statins long-term after CABG 3
• Regular cardiology follow-up improves medication adherence 4

Risk Factor Modification

• Smoking cessation counseling and therapy should be offered during hospitalization 1
• Proton pump inhibitors are recommended for patients at increased risk of gastrointestinal bleeding 1

Special Considerations

Patients with Atrial Fibrillation

• For patients with a long-term indication for oral anticoagulation (OAC):
  • Direct oral anticoagulant (DOAC) alone is preferred over vitamin K antagonist (VKA) unless contraindicated 1
  • If PCI is performed, consider triple therapy (OAC + DAPT) initially, followed by OAC plus single antiplatelet therapy 1

Patients with Diabetes

• Intensive glycemic control is essential 1
• No significant difference in outcomes between DAPT and aspirin monotherapy in diabetic patients post-CABG 2

Common Pitfalls to Avoid

1. Discontinuing statins perioperatively - This can increase morbidity and mortality 1
2. Delaying aspirin initiation - Should be started within 6 hours postoperatively if not given preoperatively 1
3. Inadequate beta-blocker management - Should be continued or initiated to reduce postoperative atrial fibrillation 1
4. Poor long-term medication adherence - Only about half of patients remain on recommended therapy years after CABG 3, 4
5. Suboptimal glycemic control - Hyperglycemia increases infection risk and other complications 1

By following these evidence-based recommendations, clinicians can optimize outcomes and reduce morbidity and mortality in patients undergoing CABG.