What medications should be prescribed to patients discharged after Coronary Artery Bypass Grafting (CABG) based on guidelines?

Medication Recommendations for CABG Discharge

All patients discharged after CABG should receive aspirin (100-325 mg daily) initiated within 6 hours postoperatively and continued indefinitely, along with statin therapy to reduce LDL cholesterol to less than 100 mg/dL, and beta-blockers to prevent post-CABG atrial fibrillation. 1, 2

Core Medication Regimen

Antiplatelet Therapy

• Aspirin: 100-325 mg daily, initiated within 6 hours postoperatively and continued indefinitely
  • Significantly improves saphenous vein graft patency rates
  • Reduces occurrence of adverse cardiovascular events
  • Dosing between 100-325 mg daily is efficacious 1
• P2Y12 inhibitor consideration:
  • For patients with recent acute coronary syndrome (ACS) or stent placement before CABG: Add a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for 12 months 1, 3
  • For patients at high risk of graft occlusion with low bleeding risk: Consider dual antiplatelet therapy 2, 4
  • Clopidogrel 75 mg daily is a reasonable alternative for patients intolerant or allergic to aspirin 1

Lipid-Lowering Therapy

• Statins: All patients should receive statin therapy unless contraindicated 1
  • Target LDL cholesterol <100 mg/dL and at least 30% reduction from baseline
  • For very high-risk patients, target LDL <70 mg/dL 1
  • Do not discontinue statin therapy before or after CABG 1

Other Essential Medications

• Beta-blockers: Should be administered to reduce incidence of postoperative atrial fibrillation 1, 2
• Nitroglycerin: Provide sublingual or spray formulation with clear instructions 1, 2
  • Instruct patients to take for chest discomfort lasting >1 minute
  • If pain doesn't subside within 3-5 minutes, call emergency services 1, 2

Special Considerations

For Patients with Diabetes

• Glucose control: Maintain blood glucose ≤180 mg/dL in the immediate postoperative period 1
• Continue appropriate diabetic medications after discharge

For Patients with Atrial Fibrillation

• Anticoagulation: Warfarin for 4 weeks is recommended for post-CABG atrial fibrillation persisting >24 hours 2

Patient Education and Follow-up

• Provide clear written and verbal instructions about:

  • Medication type, purpose, dose, frequency, and side effects 1, 2
  • Recognition of symptoms of worsening myocardial ischemia 1, 2
  • When to seek emergency care 1, 2

• Refer all patients to cardiac rehabilitation programs 2

  • Reduces cardiovascular mortality by 26% and overall mortality by 20%

Common Pitfalls to Avoid

1. Delayed initiation of aspirin: Benefits of aspirin on graft patency are lost if initiated >48 hours after surgery 1

2. Premature discontinuation of antiplatelet therapy: Particularly important for patients who had ACS or stent placement before CABG 5

3. Inadequate statin dosing: Ensure dose is sufficient to achieve target LDL reduction 1

4. Overlooking depression screening: Depression after CABG is associated with increased cardiac events and recurrent angina 2

5. Failure to provide clear instructions about nitroglycerin use and when to seek emergency care 1, 2

By following these evidence-based medication recommendations, the risk of graft occlusion, recurrent ischemic events, and mortality can be significantly reduced in patients discharged after CABG.