What are the guideline-based recommendations for a patient immediately after discharge following coronary artery bypass graft surgery?

Post-CABG Discharge Recommendations

All patients after CABG should be enrolled in cardiac rehabilitation during their surgical hospitalization, as this intervention reduces cardiovascular mortality by 20% and overall mortality through improvements in functional capacity, risk factor management, and psychosocial well-being. 1

Core Pharmacotherapy at Discharge

Essential Medications (Class I Recommendations)

• Antiplatelet therapy: Aspirin remains the cornerstone antiplatelet agent for all post-CABG patients without contraindications 2, 3
• Statins: High-intensity statin therapy should be prescribed to all patients, with 93.9% of patients receiving statins at 6 months post-discharge in registry data 4
• Beta-blockers: Should be reinstituted as soon as possible after CABG in all patients without contraindications, as they reduce mortality, prevent atrial fibrillation, and decrease perioperative myocardial ischemia 5

Medications for Specific Subgroups

• ACE inhibitors or ARBs: Recommended for patients with diabetes, renal insufficiency, LV systolic dysfunction, or heart failure 1
  • Critical caveat: Do not initiate in the immediate postoperative period if systolic BP <100 mmHg or if hypotension develops 1
  • The IMAGINE trial showed increased adverse events (particularly recurrent angina) in the first 3 months when ACE inhibitors were started early post-CABG 1
  • Consider waiting 3-6 months post-operatively before initiating in stable, low-risk patients 5

Dual Antiplatelet Therapy Considerations

• DAPT (aspirin + clopidogrel/ticagrelor) does not improve graft patency or clinical outcomes over aspirin monotherapy for on-pump CABG, and increases major bleeding risk 6
• Evidence for routine DAPT post-CABG remains unconvincing, though newer agents like ticagrelor show promise in specific populations 2

Cardiac Rehabilitation Program

Referral should occur early during the surgical hospital stay (Class I, Level A). 1

Program Components and Benefits

• Exercise training: Beginning 4-8 weeks post-CABG, three sessions weekly for 3 months produces a 35% increase in exercise tolerance and 6% reduction in body fat 1
• Risk factor management: Includes lipid control, blood pressure management, weight reduction, diabetes management, and smoking cessation 1
• Nutritional counseling: Essential for dietary modification of fat and caloric intake 1
• Psychosocial interventions: Address depression, anxiety, and facilitate self-management skills 1

Addressing Poor Utilization

• Only 31% of Medicare CABG patients receive at least one CR session despite strong evidence and insurance coverage 1
• Barriers include knowledge deficits, comorbidities, lack of support, employment issues, and sex-specific concerns (women experience fatigue and guilt about neglecting family; men face dietary dependence and employment conflicts) 1
• Key strategy: Automatic referral systems during hospitalization improve uptake compared to post-discharge referrals 1

Smoking Cessation

All smokers must receive in-hospital educational counseling and smoking cessation therapy during CABG hospitalization (Class I, Level A). 1

Evidence for Smoking Cessation Impact

• Smoking cessation produces the largest magnitude reduction in mortality compared to any other post-CABG intervention 1
• 10-year survival: 82% in quitters vs. 77% in continued smokers (p=0.025) 1
• Risk reduction for cardiac death occurs within just 1 year of cessation (RR: 0.63) 1
• Continued smoking increases risk of MI, reoperation, recurrent angina, and sudden cardiac death (HR: 2.47) 1

Pharmacotherapy for Cessation

• After hospital discharge: Nicotine replacement therapy, bupropion, and varenicline are reasonable adjuncts to counseling (Class IIa, Level B) 1
• During hospitalization: These agents may be considered but effectiveness before discharge is uncertain (Class IIb, Level C) 1

Mental Health Screening and Management

Screen for depression in collaboration with primary care and mental health specialists (Class IIa, Level B). 1

Depression Impact on Outcomes

• Depression occurs in up to 33% of patients at 1 year post-CABG 1
• Patients with major depressive disorder at discharge are nearly 3 times more likely to experience cardiac events (heart failure hospitalization, MI, cardiac arrest, repeat revascularization, or death) 1
• Depression predicts recurrence of angina during the first 5 postoperative years 1

Evidence-Based Interventions

• Collaborative care (8 months of telephone-delivered support): 50% of patients achieved 50% decline in depression scores vs. 29.6% with usual care (p<0.001) 1
• Cognitive behavioral therapy (12 weeks): Most durable effects on depression and psychological outcomes 1
• Both interventions improve quality of life and physical functioning, likely reducing morbidity and mortality 1

Medication Adherence and Outcomes

Patients taking ≤50% of indicated medications at discharge have 69% higher risk of death or MI at 2 years compared to those taking all indicated medications (adjusted HR: 1.69; 95% CI: 1.12-2.55). 3

Long-term Medication Patterns

• Medication use declines significantly over time: statins drop from 93.9% at 6 months to 77.3% at 8 years; beta-blockers from 91.0% to 76.4% 4
• Patients ≥75 years receive all medications less frequently 4
• When secondary prevention goals are not met at 1 year, adverse cardiovascular events increase regardless of baseline risk factors 1

Mortality Associations (Time-Updated Analysis)

• Statins: 44% mortality reduction (HR: 0.56; 95% CI: 0.52-0.60) 4
• RAAS inhibitors: 22% mortality reduction (HR: 0.78; 95% CI: 0.73-0.84) 4
• Platelet inhibitors: 26% mortality reduction (HR: 0.74; 95% CI: 0.69-0.81) 4
• Beta-blockers: No mortality association in long-term observational data (HR: 0.97; 95% CI: 0.90-1.06), though early post-operative benefits for AF prevention remain 4

Self-Management and Patient Education

• CR programs should provide individualized interventions addressing sex-specific barriers: women struggle with fatigue, anxiety, depression, and guilt; men face comprehension issues and dietary/activity barriers 1
• 35% of women stop exercising within 3 months of CR discharge, requiring targeted support 1
• Self-management skills facilitate patients' control over diet, exercise, and medication adherence 1

Economic Benefits

• CR participation reduces per capita hospitalization charges by $739 over 21 months compared to non-participants 1
• Greater medication adherence and CR participation improve long-term outcomes and reduce healthcare utilization 3