Goals of Therapy Post-CABG
Cardiac rehabilitation (CR) is strongly recommended for all patients after CABG, with referral ideally performed early during the surgical hospital stay to reduce cardiovascular mortality by 26% and overall mortality by 20%. 1
Medication Management
Antiplatelet Therapy
- Aspirin (75-100mg daily) should be started within 6 hours postoperatively and continued indefinitely to reduce saphenous vein graft closure 1, 2
- For patients with acute coronary syndrome who undergo CABG, P2Y12 inhibitor therapy should be resumed to complete 12 months of dual antiplatelet therapy 2
- Ticagrelor may be superior to aspirin alone for preventing graft occlusion, as it reduced the proportion of patients with graft occlusion in a small study 3
Lipid Management
- High-intensity statin therapy should be initiated immediately after CABG and continued indefinitely 1, 2
- Statin therapy is associated with reduced perioperative mortality (approximately 50% reduction) 5
- Patients in whom statins were discontinued after CABG have higher mortality rates than those who continued 1
Other Cardiovascular Medications
- Beta-blockers should be started as soon as possible after CABG and continued indefinitely to prevent postoperative atrial fibrillation 1, 2
- ACE inhibitors or ARBs should be initiated postoperatively and continued indefinitely, especially in patients with:
- Left ventricular ejection fraction ≤40%
- Hypertension
- Diabetes mellitus
- Chronic kidney disease 2
Glycemic Control
- Continuous intravenous insulin should be used to achieve and maintain early postoperative blood glucose ≤180 mg/dL while avoiding hypoglycemia 1, 2
- Tight glycemic control reduces the incidence of deep sternal wound infections and other adverse events 2
- For long-term management, target HbA1c between 6-7% 2
- Consider SGLT-2 inhibitors and GLP-1 receptor agonists for long-term diabetes management due to their cardiovascular benefits 2
Smoking Cessation
- Smoking cessation counseling should be offered to all patients who smoke during and after hospitalization 1, 2
- Pharmacological therapy including nicotine replacement, bupropion, and varenicline should be offered to patients willing to quit 1
- Smoking cessation is critical for improving both short- and long-term clinical outcomes after surgery 1
Cardiac Rehabilitation Components
CR programs should include:
- Baseline patient assessments
- Nutritional counseling (Mediterranean diet recommended)
- Risk factor management (lipids, blood pressure, weight, diabetes, smoking)
- Psychosocial interventions
- Physical activity with counseling and exercise training 1, 2
Monitoring and Follow-up
- Continuous electrocardiographic monitoring for at least 48 hours after CABG 2
- Regular follow-up visits to assess:
- Blood pressure control
- Lipid levels
- Glycemic control
- Medication adherence
- Symptoms of recurrent ischemia 2
- Screen for depression, which affects adherence to therapy 1, 2
- Consider cognitive behavior therapy for patients with clinical depression 2
Common Pitfalls and Barriers to Optimal Post-CABG Care
Poor CR referral patterns: Despite strong evidence supporting CR, only 31% of CABG patients receive at least one session 1
- Solution: Implement systematic referral processes during hospitalization
Medication non-adherence: Up to 24% of patients discontinue antilipid agents within 12 months 6
- Solution: Emphasize the importance of medication adherence at discharge and follow-up visits
Gender-specific barriers:
Inadequate secondary prevention: When prevention goals are not met at 1 year, the incidence of adverse cardiovascular events increases 1
- Solution: Regular follow-up to ensure achievement of prevention goals
The evidence strongly supports comprehensive secondary prevention through cardiac rehabilitation, optimal medication management, and lifestyle modifications to reduce morbidity and mortality following CABG surgery.