Can a patient with a history of Coronary Artery Bypass Graft (CABG) surgery take Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)?

NSAID Use After CABG: Recommendations and Safety Considerations

Patients with a history of CABG can take NSAIDs for pain management, but this should be done with significant caution and only in carefully selected patients without high-risk features such as renal impairment, heart failure, or recent thrombotic events. 1

Primary Guideline Recommendations

Post-CABG Antithrombotic Therapy Framework

• Low-dose aspirin (75-100 mg daily) is recommended lifelong after CABG, and this should be continued until the day of surgery and restarted within 24 hours postoperatively when there is no bleeding concern. 1
• Patients with prior CABG who develop acute coronary syndromes should receive guideline-directed medical therapy including antiplatelet and anticoagulant therapy. 1

NSAID Safety Considerations in Post-CABG Patients

The critical issue is not an absolute contraindication to NSAIDs after CABG, but rather careful patient selection and risk stratification. The evidence shows NSAIDs can be used safely in selected post-CABG patients, but several high-risk conditions must be excluded first.

Absolute Contraindications to NSAIDs After CABG

Renal Impairment

• NSAIDs should be avoided entirely in patients with pre-existing renal disease, estimated creatinine clearance <50 mL/min, or congestive heart failure. 1, 2
• The kidney relies on prostaglandins for maintaining adequate renal perfusion, and NSAIDs inhibit this protective mechanism, leading to volume-dependent renal failure, particularly in compromised states. 1, 2
• Approximately 2% of patients taking NSAIDs will discontinue them due to renal complications. 2

Heart Failure

• Patients with heart failure should not receive NSAIDs, as they cause sodium and water retention, worsen renal function, and can precipitate acute decompensation. 2, 3
• NSAIDs directly reduce sodium excretion and blunt the natriuretic response to diuretics, with an average blood pressure increase of 5 mm Hg. 2

Concurrent Anticoagulation

• When NSAIDs are combined with anticoagulants, there is a 3- to 6-fold increased risk of gastrointestinal bleeding due to both drug interactions and direct antiplatelet effects. 1
• Patients requiring therapeutic anticoagulation should avoid NSAIDs or receive intensive gastrointestinal prophylaxis with proton pump inhibitors. 1

Relative Contraindications and High-Risk Features

Medication Interactions

• The combination of NSAIDs with ACE inhibitors or angiotensin receptor blockers significantly increases the risk of renal complications. 1, 2
• When NSAIDs must be used with these medications, weekly renal function monitoring for the first three weeks is recommended in high-risk patients. 1, 2

Gastrointestinal Risk

• NSAIDs may provoke gastrointestinal bleeding, especially in elderly patients, those with history of GI bleeding or peptic disease, high alcohol consumption, chronic steroid use, or receiving combination antithrombotic therapy. 1
• Gastric protection with proton pump inhibitors is recommended for as long as antithrombotic therapy is administered in high-risk patients. 1

Cardiovascular Thrombotic Events

• NSAIDs carry a boxed warning for increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, with risk potentially occurring early in treatment. 3
• COX-2 inhibitors are contraindicated in patients with history of atherothrombosis, and non-selective NSAIDs should be limited to ≤7 days in these patients. 3

When NSAIDs Can Be Used Safely After CABG

Evidence Supporting Selective Use

• Research demonstrates that NSAIDs can be used safely for postoperative pain management in selected CABG patients without the high-risk features listed above. 4, 5, 6
• A study of indomethacin after CABG showed it was safe and possibly effective for reducing chest tube duration (94 hours in controls vs 82.8 hours with indomethacin, P=0.041). 4
• Diclofenac 75 mg given post-CABG reduced morphine requirements compared to placebo without differences in creatinine elevation rates. 5

Practical Algorithm for NSAID Use After CABG

Step 1: Exclude Absolute Contraindications

• Creatinine clearance <50 mL/min 2, 3
• Heart failure or cirrhosis 2
• Active or recent GI bleeding 1
• Therapeutic anticoagulation without GI prophylaxis 1

Step 2: Assess Relative Risk Factors

• Age >60 years 2
• Concurrent ACE inhibitor or ARB use 1, 2
• History of peptic ulcer disease 1
• Chronic steroid use 1
• Recent acute coronary syndrome (<6 months) 3

Step 3: If NSAIDs Are Appropriate

• Use the lowest effective dose for the shortest duration 2
• Limit duration to ≤7 days in patients with atherothrombotic disease 3
• Ensure adequate hydration 2
• Consider GI prophylaxis with proton pump inhibitors in high-risk patients 1
• Monitor renal function if risk factors present 1, 2

Step 4: Preferred Alternatives

• Acetaminophen up to 3-4 g/day is the preferred first-line analgesic for patients with any contraindications to NSAIDs. 2, 3, 7
• Multimodal analgesia approaches combining acetaminophen with regional anesthesia techniques can minimize NSAID requirements. 3

Monitoring Requirements

For High-Risk Patients Receiving NSAIDs

• Obtain baseline serum creatinine before initiating NSAIDs 2
• Monitor renal function weekly for three weeks after initiation in high-risk patients 1, 2
• Monitor blood pressure, as NSAIDs can increase BP by average of 5 mm Hg 2
• Monitor for signs of fluid retention or heart failure decompensation 2

Discontinuation Criteria

• Stop NSAIDs immediately if creatinine doubles from baseline 2
• Discontinue if GFR drops to <20 mL/min/1.73 m² 2
• Stop if new or worsening hypertension develops 2
• Discontinue if signs of GI bleeding occur 1

Common Pitfalls to Avoid

• Do not assume COX-2 selective inhibitors are safer for renal or cardiovascular effects—they produce identical sodium retention and cardiovascular risks as non-selective NSAIDs. 2, 3
• Do not overlook over-the-counter NSAID use—patients often self-medicate with ibuprofen or naproxen without informing providers, which can undermine therapy and cause complications. 2
• Do not combine multiple NSAIDs simultaneously, as this increases the risk of kidney injury. 2
• Do not use sulindac or diclofenac in patients with any hepatic concerns, as these have additional hepatotoxicity beyond their renal effects. 2