What are the postoperative management and medications for a patient who has undergone Coronary Artery Bypass Grafting (CABG)?

Post-CABG Management and Medications

All CABG patients should receive aspirin (75-325 mg daily) started within 6 hours postoperatively and continued indefinitely, combined with beta-blockers reinstituted as soon as possible after surgery, along with strict glycemic control targeting blood glucose <180 mg/dL using continuous insulin infusion. 1, 2

Immediate Postoperative Management (First 24-48 Hours)

Glycemic Control

• Initiate continuous intravenous insulin infusion intraoperatively and continue postoperatively to maintain blood glucose <180 mg/dL to reduce deep sternal wound infections and adverse events 1
• Target range of <150 mg/dL is associated with markedly lower risks of death and sternal wound infections 1
• Avoid hypoglycemia while maintaining tight glucose control 1

Antiplatelet Therapy

• Start aspirin 75-325 mg (preferably 81 mg) within 6 hours postoperatively to reduce mortality, MI, stroke, renal failure, and bowel infarction 1, 2
• Aspirin is the standard of care for preventing early saphenous vein graft closure and should be continued indefinitely 1

Beta-Blocker Management

• Reinstitute beta-blockers as soon as possible postoperatively in all patients without contraindications to reduce atrial fibrillation incidence and clinical sequelae 1
• Beta-blockers should have been administered for at least 24 hours preoperatively 1
• Intravenous administration is reasonable in clinically stable patients unable to take oral medications 1

Anesthetic Recovery

• Target early extubation and accelerated recovery protocols in low- to medium-risk patients with uncomplicated CABG 1
• Monitor hemodynamics closely during transition from anesthesia, particularly when weaning from cardiopulmonary bypass 1

Dual Antiplatelet Therapy (DAPT) Considerations

For Patients with Prior Stent Placement

• Resume P2Y12 inhibitor therapy postoperatively to complete the recommended duration of DAPT if patient had coronary stent implantation before CABG 1
• Continue DAPT until the originally planned duration is completed 1

For Patients with Acute Coronary Syndrome

• Resume P2Y12 inhibitor therapy after CABG to complete 12 months of DAPT in patients with NSTE-ACS or STEMI 1
• Clopidogrel should be initiated early postoperatively 1

For Stable Ischemic Heart Disease

• DAPT with clopidogrel for 12 months after CABG may be reasonable to improve vein graft patency, though this is a weaker recommendation 1
• This applies specifically to patients without contraindications or high bleeding risk 1

P2Y12 Inhibitor Timing

• If clopidogrel or ticagrelor was held preoperatively, it should have been withheld for at least 5 days before surgery 1
• Prasugrel should have been withheld for at least 7 days 1

Atrial Fibrillation Prophylaxis and Management

Primary Prevention

• Beta-blockers are the standard first-line therapy for reducing postoperative atrial fibrillation incidence 1
• Beta-blockers should be prescribed at hospital discharge to all patients without contraindications 1

Alternative Prophylaxis

• Preoperative amiodarone is reasonable for patients at high risk for postoperative AF who have contraindications to beta-blockers 1
• Low-dose sotalol can be considered in patients who are not candidates for traditional beta-blockers 1

Rate Control if AF Occurs

• Digoxin and nondihydropyridine calcium channel blockers are useful for ventricular rate control but not for prophylaxis 1
• Esmolol has rapid onset and is easily titrated for acute rate control 3

Lipid Management

Statin Therapy

• Continue or initiate high-intensity statin therapy with target LDL cholesterol <100 mg/dL and at least 30% reduction from baseline 2, 4
• Atorvastatin 80 mg daily significantly reduces major cardiovascular events compared to lower doses in post-CABG patients 4
• Statin therapy should be continued unless contraindicated 2

Blood Conservation and Transfusion Management

Intraoperative Strategies

• Use lysine analogues intraoperatively and postoperatively during on-pump CABG to reduce perioperative blood loss and transfusion requirements 1
• Implement multimodal approach with transfusion algorithms and point-of-care testing 1
• Consider off-pump CABG to reduce perioperative bleeding and allogeneic blood transfusion 1

Anticoagulant Management

• Tirofiban or eptifibatide should be discontinued at least 2-4 hours before CABG 1
• Abciximab should be discontinued at least 12 hours before CABG 1
• Delay surgery after streptokinase, urokinase, and tissue-type plasminogen activators until hemostatic capacity is restored 1

Infection Prevention

Antibiotic Prophylaxis

• Preoperative antibiotic administration should be used in all patients to reduce postoperative infection risk 1

Deep Sternal Wound Infection Management

• Treat with aggressive surgical debridement and early revascularized muscle flap coverage in the absence of complicating circumstances 1
• Aggressive glycemic control with continuous insulin infusion reduces deep sternal wound infection risk 1

Hospital Discharge Medications

Essential Medications at Discharge

• Aspirin 81 mg daily indefinitely 1
• Beta-blocker therapy (unless contraindicated) 1
• High-intensity statin (atorvastatin 80 mg or equivalent) 2, 4
• P2Y12 inhibitor (clopidogrel 75 mg daily) if indicated based on ACS presentation or prior stent 1, 5

Risk Factor Modification

• All smokers should receive educational counseling and smoking cessation therapy including nicotine replacement and bupropion in select patients 1
• Continue ACE inhibitors or ARBs if previously prescribed, though careful monitoring is needed perioperatively due to hypotension risk 1

Special Considerations

Concomitant Valve Procedures

• Patients who underwent concomitant aortic valve replacement for severe stenosis (mean gradient ≥50 mm Hg) require standard valve management protocols 1
• Those with mitral valve repair or replacement for clinically significant regurgitation need appropriate anticoagulation based on valve type 1

Renal Protection

• In patients with preexisting renal dysfunction, delay surgery after coronary angiography until contrast effect on renal function is assessed 1
• Maintain adequate hydration with careful fluid balance monitoring to prevent hyperosmotic dehydration 2

High-Risk Patients

• Intra-aortic balloon pump insertion is reasonable in high-risk patients (reoperation, LVEF <30%, or left main CAD) to reduce mortality 1
• Measure biomarkers of myonecrosis (creatine kinase-MB, troponin) in the first 24 hours after CABG 1

Common Pitfalls to Avoid

• Do not delay aspirin initiation beyond 6 hours postoperatively, as early administration (within 48 hours) significantly reduces mortality and major complications 2
• Do not restart P2Y12 inhibitors too early if they were appropriately held preoperatively; resume only after adequate hemostasis is achieved postoperatively 1
• Do not use digoxin or calcium channel blockers for AF prophylaxis; they are only for rate control once AF occurs 1
• Do not allow blood glucose to exceed 180 mg/dL in the perioperative period, as this significantly increases infection and mortality risk 1
• Do not prescribe beta-blockers at discharge without ensuring they were tolerated postoperatively, though they should be given to all patients without contraindications 1