What is the treatment for ST elevation after Coronary Artery Bypass Grafting (CABG)?

Treatment of ST Elevation After CABG

Patients with ST elevation after CABG should be urgently evaluated with transthoracic echocardiography to rule out mechanical complications and determine appropriate treatment based on the underlying cause. 1

Initial Evaluation

• Immediate Doppler echocardiography is indicated to assess ventricular and valvular functions, loading conditions, and to detect mechanical complications 1
• Continuous ECG monitoring with defibrillator capacity should be maintained in all patients with ST elevation after CABG 2
• Invasive blood pressure monitoring with an arterial line is recommended for hemodynamic assessment 1

Management Algorithm Based on Underlying Cause

1. Graft Failure/Occlusion

• If graft failure is suspected and the patient has:

  • Hemodynamic instability or cardiogenic shock: Emergency coronary angiography with potential for PCI is indicated 1
  • Severe ongoing ischemia or life-threatening arrhythmias: Urgent coronary angiography within the first hour is recommended 1
  • Stable condition: Coronary angiography should be performed within 48 hours 1

• If PCI is not feasible due to unsuitable coronary anatomy:

  • Emergency CABG is recommended, especially if the patient is in cardiogenic shock 1

2. Cardiogenic Shock

• For patients with cardiogenic shock after CABG:
  • Intra-aortic balloon pump counterpulsation should be considered, especially if due to mechanical complications 1
  • Alternative left ventricular assist devices may be considered for refractory shock 1
  • Complete revascularization should be considered during the index procedure 1
  • Hemodynamic assessment with pulmonary artery catheter may be considered for confirming diagnosis or guiding therapy 1

3. Arrhythmias

• For life-threatening ventricular arrhythmias:
  • Immediate electrical cardioversion is indicated for hemodynamically unstable patients 1
  • Antiarrhythmic drugs should be used cautiously due to potential negative effects on mortality 1
  • Correction of electrolyte imbalances is recommended 1
  • Early treatment with beta-blockers, ACE inhibitors/ARBs, and statins is recommended 1

4. ST Elevation Without Significant Complications

• For ST elevation after CABG without evidence of perioperative MI or hemodynamic compromise:
  • Continue monitoring as this may not be associated with increased postoperative morbidity or mortality 3
  • Maintain antiplatelet therapy with aspirin (75-325 mg daily) 1, 4
  • Consider high-intensity statin therapy 1

Antiplatelet and Anticoagulation Management

• Aspirin should not be withheld before or after urgent CABG 1
• Aspirin (75-325 mg daily) should be prescribed as soon as possible (within 24 hours) after CABG unless contraindicated 1, 4
• For patients requiring dual antiplatelet therapy:
  • If clopidogrel or ticagrelor was administered, it should be discontinued at least 24 hours before urgent on-pump CABG, if possible 1
  • Short-acting intravenous GP IIb/IIIa receptor antagonists should be discontinued at least 2-4 hours before urgent CABG 1
  • Bridge therapy with tirofiban may be considered in patients who recently underwent PCI prior to CABG 5

Timing Considerations for Repeat CABG

• If repeat CABG is needed, timing is critical:
  • CABG mortality is elevated for the first 3-7 days after infarction 1
  • For stabilized patients with significant LV dysfunction, surgery should be delayed to allow myocardial recovery 1
  • Performing CABG beyond 72 hours following admission may be associated with lower risk 6

Important Caveats and Pitfalls

• ST elevation after CABG without evidence of perioperative MI is relatively common (occurring in approximately 12.6% of cases) and may not necessarily indicate a poor prognosis 3
• Female sex, elevated preoperative cardiac troponin I levels, and preoperative cardiogenic shock are major predictors of mortality and morbidity after CABG in STEMI patients 7
• Routine intra-aortic balloon pumping is not indicated in all cases of ST elevation after CABG 1
• The benefit of antiarrhythmic drugs in this setting is limited, and negative effects on early mortality have been demonstrated 1
• Avoid glucocorticoids and nonsteroidal anti-inflammatory drugs for treatment of post-CABG pericarditis as they are potentially harmful 1