Timing of CABG After STEMI
For hemodynamically stable STEMI patients with preserved left ventricular function requiring CABG, surgery can be performed within several days without increased risk, but delaying beyond 24 hours (ideally 3-7 days) significantly reduces surgical complications and mortality compared to operating within the first 24 hours. 1
Emergency/Urgent CABG (Immediate to <24 Hours)
Perform CABG immediately or within hours only in these specific situations:
- Cardiogenic shock: Emergency revascularization with CABG is indicated regardless of time delay from MI onset 1
- Failed PCI with large area of myocardium at risk: Emergency CABG can be effective when PCI is not feasible or unsuccessful 1
- Anatomy unsuitable for PCI: Urgent CABG is indicated when coronary angiogram reveals anatomy that cannot be treated percutaneously 1
- Ongoing ischemia with hemodynamic compromise or life-threatening arrhythmias: Critical anatomy requiring revascularization during index hospitalization 1
Critical caveat: Surgery within 24 hours carries significantly higher risks. Patients undergoing CABG within 24 hours have increased cardiac complications (OR 1.33-1.39), respiratory complications (OR 1.31-1.53), renal complications (OR 1.31), bleeding (OR 1.20), and in-hospital mortality (8.2% vs 2.9-3.5% for delayed surgery) 2. Rethoracotomy rates are markedly higher when operating within 3 days versus after 3 days (33% vs 5%) 3.
Optimal Timing for Stable Patients
For stabilized patients (no ongoing ischemia, hemodynamic compromise, or life-threatening arrhythmia):
- Delay surgery 3-7 days after infarction to allow myocardial recovery, particularly if significant fall in LV function has occurred 1
- Surgery between days 4-7 shows optimal outcomes: Mortality drops to 2.9% compared to 8.2% within 24 hours 2
- Stable STEMI patients with preserved LV function can undergo CABG within several days without increased risk 1
The most recent 2025 ACC/AHA guidelines emphasize that timing should be determined individually based on hemodynamic stability, presence of ongoing ischemia, and extent of myocardium at risk 1. However, the evidence clearly favors delaying beyond 24 hours when clinically feasible.
Antiplatelet Management
Critical timing considerations for antiplatelet agents:
- Aspirin: Do NOT withhold before urgent or elective CABG 1
- Clopidogrel/ticagrelor: Discontinue at least 24 hours before urgent CABG (Class I), ideally 5 days for elective cases 1
- Prasugrel: Discontinue at least 7 days before elective CABG 1
- GP IIb/IIIa inhibitors (eptifibatide, tirofiban): Discontinue 2-4 hours before surgery 1
- Abciximab: Discontinue at least 12 hours before surgery 1
Off-pump CABG within 24 hours of clopidogrel/ticagrelor may be considered when benefits of prompt revascularization outweigh bleeding risks (Class IIb) 1.
Evidence Quality and Nuances
The 2004 ACC/AHA guidelines 1 established the 3-7 day window based on elevated CABG mortality in the first 3-7 days post-infarction. More recent observational data from 2020 2 with 5,963 patients provides the strongest evidence that delaying beyond 24 hours reduces complications and mortality. A 2017 single-center study 4 showed excellent outcomes with surgery within 48 hours (30-day mortality 2.7% for STEMI), particularly when performed within 6 hours for truly emergent cases (1.8% mortality).
The key distinction: Emergency surgery for unstable patients or failed PCI must proceed immediately despite higher risks, while stable patients benefit from a 3-7 day delay to allow myocardial recovery and reduce surgical bleeding complications.