What are the goals of therapy for coronary artery disease post Coronary Artery Bypass Grafting (CABG)?

Goals of Therapy for Coronary Artery Disease Post CABG

The primary goals of therapy for coronary artery disease post CABG are to reduce mortality, prevent graft occlusion, reduce major adverse cardiovascular events, and improve quality of life through aggressive risk factor modification and evidence-based pharmacotherapy. 1, 2

Pharmacological Management

Antiplatelet Therapy

• Aspirin (81-325 mg daily) should be initiated within 6 hours postoperatively and continued indefinitely to prevent saphenous vein graft closure and reduce adverse cardiovascular events 1, 2
  • For patients on ticagrelor, the aspirin dose should be limited to 81 mg daily 1
• Consider dual antiplatelet therapy:
  • In addition to aspirin, a P2Y12 inhibitor (clopidogrel or ticagrelor) may be continued for up to 12 months in selected patients 1
  • Some evidence suggests dual antiplatelet therapy improves early venous graft patency compared to aspirin alone (91.6% vs 85.7% at 3 months) 3
  • However, this benefit must be balanced against increased bleeding risk 4

Lipid Management

• High-intensity statin therapy is indicated for all patients post-CABG unless contraindicated 1, 2
  • Target LDL-C <100 mg/dL with at least 30% reduction from baseline 1
  • Atorvastatin 80 mg daily has been shown to reduce major cardiovascular events by 22% compared to 10 mg daily 5
  • Statins should never be discontinued before or after CABG in patients without adverse reactions 1

Beta-Blockers

• Should be administered for at least 24 hours before CABG when possible 1
• Should be reinstituted as soon as possible after CABG and continued indefinitely to reduce the incidence of postoperative atrial fibrillation 1, 2

Glycemic Control

• Continuous intravenous insulin should be used to achieve and maintain early postoperative blood glucose ≤180 mg/dL while avoiding hypoglycemia 1
• Long-term glycemic control should target appropriate HbA1c levels based on individual patient factors 2

Risk Factor Modification

Smoking Cessation

• All smokers should receive in-hospital educational counseling and be offered smoking cessation therapy during CABG hospitalization 1
• Smoking cessation after CABG is associated with substantial reduction in subsequent major adverse cardiac events, including MI and death 1
• Data from the CASS study showed 10-year survival rates of 82% among patients who quit smoking after CABG compared to only 77% in those who continued to smoke 1

Cardiac Rehabilitation

• All patients should be enrolled in a structured cardiac rehabilitation program 2, 6
• Programs should include:
  • Baseline patient assessments
  • Nutritional counseling
  • Risk factor management
  • Psychosocial interventions
  • Physical activity with counseling and exercise training 2

Follow-up and Monitoring

Regular Assessment

• Continuous electrocardiographic monitoring for at least 48 hours post-CABG 2
• Regular follow-up visits to assess:
  • Blood pressure control
  • Lipid levels
  • Glycemic control
  • Medication adherence
  • Symptoms of recurrent ischemia 2

Depression Screening

• Screen for depression, which is common after CABG and affects adherence to therapy 2

Common Pitfalls to Avoid

1. Inadequate antiplatelet therapy: Failure to initiate aspirin within 6 hours postoperatively can increase risk of early graft thrombosis 1, 2

2. Discontinuation of statins: Discontinuing statin therapy before or after CABG can lead to increased cardiovascular events 1

3. Neglecting smoking cessation: Continued smoking after CABG is associated with significantly higher rates of MI, reoperation, and death 1

4. Poor cardiac rehabilitation referral: Despite proven benefits, many patients are not referred to cardiac rehabilitation programs 2

5. Suboptimal secondary prevention: When prevention goals are not met at 1 year, the incidence of adverse cardiovascular events increases significantly 2, 7

By focusing on these therapeutic goals with aggressive risk factor modification and evidence-based pharmacotherapy, patients can achieve optimal outcomes following CABG surgery, with reduced mortality, improved graft patency, and better quality of life.