Version May 2024
INTRODUCTION — The treatment of coronary heart disease (CHD) has evolved significantly over the past several years due in part to improvement in both surgical and percutaneous revascularization techniques. The majority of patients with chronic stable angina are still treated with medical therapy; however, revascularization with either coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention should be considered in several subgroups. (See "Chronic coronary syndrome: Indications for revascularization".)
The medical therapies that can minimize the short-term, particularly perioperative complications that can occur following conventional CABG (using cardiopulmonary bypass) will be reviewed here. A general discussion of the early complications of CABG is presented separately. (See "Early noncardiac complications of coronary artery bypass graft surgery".)
SECONDARY PREVENTION MEDICATIONS
Aspirin — Aspirin should be administered to all patients without a contraindication who have cardiovascular disease. (See "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease".)
With respect to efficacy in patients undergoing coronary artery bypass graft surgery (CABG), a systematic review from the Antiplatelet Trialists' Collaboration concluded that antiplatelet therapy, particularly if given early, was associated with improved graft patency at an average of one year after surgery (pooled odds reduction for graft closure of 44 percent) [1]. This benefit was similar with low-dose aspirin (75 to 325 mg/day) as with higher and more gastrotoxic doses. Antacids and proton pump inhibitors are commonly given in the perioperative period to further attenuate this risk.
Preoperative aspirin — All patients with cardiovascular disease (CVD) should receive lifelong aspirin to prevent ischemic cardiovascular events. Thus, most patients referred for CABG take aspirin daily and we continue aspirin until surgery. For patients with a new diagnosis of CVD (and not taking aspirin) and who need CABG, the decision to start aspirin preoperatively should be individualized, taking into account the duration of the delay to surgery (ie, risk of an ischemic event in the interval between diagnosis and CABG), the bleeding risk at the time of surgery, and potential problems associated with starting a new medication shortly before surgery. If the delay is more than five days, we start aspirin in most cases. If the delay is less than five days, most of our experts start aspirin in patients not at high bleeding risk.
In general, the decision to start or to continue aspirin prior to CABG needs to balance the risks of excess bleeding with potential benefits such as increased graft patency or survival or a lower rate of perioperative ischemic events [2,3]. The following studies attempted to clarify the role of aspirin in patients who will be having CABG within four or five days.
The ATACAS trial randomly assigned 2100 stable CABG patients to aspirin (100 mg) or placebo administered one to two hours before surgery [4]. Patients enrolled in the trial were not taking aspirin prior to enrollment or stopped taking aspirin for at least five days before CABG. There was no difference in the rate of the primary outcome (death, nonfatal myocardial infarction, stroke, pulmonary embolism, renal failure, or bowel infarction) within 30 days (19.3 versus 20.4 percent; relative risk 0.94, 95% CI 0.80-1.12). There were similar rates of major hemorrhage leading to reoperation (1.8 versus 2.1 percent), cardiac tamponade (1.1 versus 0.4 percent), and mortality (1.3 versus 0.9 percent). At one year, the rates of the combined outcome of death or severe disability (the primary outcome) were similar between groups, as were the rates of death, stroke, or myocardial infarction [5].
Older (than ATACAS) studies had come to differing conclusions regarding the net benefit and harm of preoperative aspirin:
●Randomized trials published in 1990 and 1991 found that preoperative aspirin therapy increased the need for reoperation for postoperative bleeding (6.6 versus 1.7 percent and 6.3 versus 2.4 percent in two trials) [2,3]. However, later observational studies found no increase in bleeding [6,7]. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding'.)
●The issue of whether preoperative aspirin decreases the risk of early vein graft occlusion was addressed in two Veterans Administration randomized trials. The first (1988) compared aspirin 325 mg daily, aspirin 325 mg three times daily, aspirin plus dipyridamole three times daily, sulfinpyrazone, and placebo. All therapy, except aspirin was started 48 hours before surgery and aspirin was given 12 hours before surgery. At 60 days, all regimens improved graft patency compared with placebo; however, the rate of reoperation after CABG was increased. The second trial (1991) compared the efficacy of aspirin (325 mg) or placebo given the night before surgery, with postoperative aspirin being given to all patients beginning six hours after surgery [2]. There was no difference in saphenous vein graft occlusion between the two groups at an average of eight days after surgery (7.4 versus 7.8 percent), but there was a nonsignificant trend toward a lower rate of occlusion of internal thoracic artery grafts (0 versus 2.4 percent) for the group receiving aspirin preoperatively.
●Observational data suggest that preoperative aspirin may reduce in-hospital mortality [6,7]. This finding differs from that found in ATACAS.
●The benefits and risk of preoperative aspirin were evaluated in a study of over 4143 patients undergoing CABG at the Cleveland Clinic, some of whom had aspirin discontinued six or more days before surgery and some within five days of surgery [8]. Among 1519 well-matched pairs of patients, there was no significant difference between those with early and late aspirin discontinuation with regard to the composite outcome of in-hospital mortality, myocardial infarction, and stroke (1.7 versus 1.8 percent). Use within five days was associated with a significantly greater rate of intraoperative transfusions (23 versus 20 percent), but a nonsignificant difference in the number of reoperations for bleeding (3.4 versus 2.4 percent).
Postoperative aspirin — Aspirin therapy in the early postoperative period appears to have significant mortality and morbidity benefits in patients who undergo CABG. This was suggested in an initial randomized trial in which 407 patients were assigned to either placebo or to dipyridamole (begun two days before surgery) plus aspirin (begun seven hours after surgery) [9]. Antiplatelet therapy significantly reduced the rate of graft occlusion at 30 days (6 versus 22 percent).
A benefit from postoperative aspirin was also suggested in a prospective observational study of over 5000 patients who survived the first 48 hours after surgery [10]. Among patients treated with antiplatelet agents, such therapy was discontinued before surgery in 50 percent; after surgery, aspirin (at a dose of up to 650 mg) was given at the discretion of the physician.
The following benefits were noted in the 60 percent of patients who received aspirin within 48 hours of revascularization (deaths or complications occurring before 48 hours were excluded from the analysis):
●Aspirin was associated with significant reductions in subsequent in-hospital mortality (1.3 versus 4.0 percent), myocardial infarction (MI) (2.8 versus 5.4 percent), stroke (1.3 versus 2.6 percent), acute renal failure (0.9 versus 3.4 percent), and bowel infarction (0.3 versus 0.8 percent).
●The mortality benefit with aspirin was seen in all subgroups, but was much less (27 percent reduction) and not significant when aspirin was begun after 48 hours.
●Small differences between the study groups could not account for the difference in outcomes. Furthermore, on multivariate analysis, no other factor or medication was independently associated with reduced rates of the above outcomes.
●There was no increase in the rate of bleeding, gastritis, infection, or impaired wound healing.
●The practices of giving platelet transfusions after reperfusion and of administering antifibrinolytic drugs (such as aminocaproic acid) to minimize postoperative bleeding were associated with increases in mortality and ischemic complications in both aspirin users and nonusers; however, the outcomes were again better with aspirin therapy. The adverse effects of antifibrinolytic therapy in this report are in contrast to a number of other studies that have demonstrated no adverse effect on or a reduction in perioperative mortality. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding'.)
Aspirin summary — In the past, concerns about bleeding risk led to the recommendation that aspirin be discontinued three to five days before surgery in patients undergoing elective CABG. However, this general approach is no longer recommended. The 2015 American Heart Association Scientific Statement on “Secondary Prevention after Coronary Artery Bypass Graft Surgery” recommended that aspirin be started or continued preoperatively [11].
In patients at increased risk of a cardiovascular thrombotic event, we typically continue aspirin until the day of surgery.
Among stable patients not previously on aspirin, benefit may be seen with aspirin started one hour after surgery [12,13]. However, with increasing experience, some surgeons recommend continuation of aspirin throughout the preoperative period. As noted above, preoperative aspirin may be associated with a significant reduction in in-hospital mortality without a significant increase in bleeding [6,7,14,15]. Furthermore, cessation of aspirin before CABG may be associated with an increase in in-hospital mortality [10]. (See 'Preoperative aspirin' above.)
We suggest that, in patients already being treated, aspirin be continued perioperatively with the possible exception of those at very high risk for bleeding. Some of the deleterious effects of aspirin and other antiplatelet drugs on postoperative bleeding and transfusion requirements can be attenuated by antifibrinolytic therapy. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Bleeding'.)
We start or restart aspirin (with or without a loading dose) six hours after surgery or after extubation, whichever comes first. The decision of whether to give a loading dose (eg, 325 mg) of aspirin may be influenced by clinical factors such as recent acute coronary syndrome or concern about a risk of early graft failure. Low-dose aspirin should be continued indefinitely. With regard to timing and dose, bleeding risk needs to be considered.
Maintenance aspirin (usually 75 or 81 mg/day) is continued indefinitely for secondary prevention [16]. Clopidogrel (75 mg/day) is an alternative in patients with contraindications or allergies to aspirin. (See "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease", section on 'Efficacy' and "Introduction of aspirin to patients with aspirin hypersensitivity requiring cardiovascular interventions".)
Aspirin also prevents saphenous vein graft stenosis. (See "Coronary artery bypass graft surgery: Prevention and management of vein graft stenosis", section on 'Antiplatelet agents'.)
The benefits of aspirin therapy and the adverse effect of platelet transfusion suggest that platelet activation plays an important role in the ischemic response to reperfusion injury [12,17].
Platelet P2Y12 receptor blocker therapy
Preoperative P2Y12 management — For patients undergoing elective coronary artery bypass graft surgery (CABG) who are taking an oral platelet P2Y12 receptor blocker (ie, clopidogrel, prasugrel, ticagrelor), we discontinue it five to seven days before surgery. This practice is based on our clinical experience and observational study results. As examples:
●In a post-hoc analysis of a randomized trial that compared clopidogrel with placebo in patients with non-ST-elevation MI, 93 percent of patients stopped the study medication prior to CABG surgery [18]. Patients who stopped clopidogrel >5 days prior to surgery had a lower risk of life-threatening and major bleeding events (4.4 versus 9.6 percent in those stopping clopidogrel ≤5 days prior to surgery, relative risk [RR] 0.45, 95% CI 0.27-0.76).
●In a sub-study of another randomized trial that compared clopidogrel with placebo in patients who received thrombolytics for ST-elevation MI, the study medication was stopped ≤5 days prior to CABG surgery in 54 percent of patients and was stopped >5 days prior to surgery in the remainder of patients [19]. The group of patients stopping clopidogrel >5 days prior to surgery had nonsignificantly lower rates of major and minor bleeding (6 versus 11 percent in the group stopping clopidogrel ≤5 days prior to surgery; RR 0.59, 95% CI 0.12-3.02).
We do not test for platelet reactivity in patients who recently took clopidogrel and who are scheduled for urgent CABG, though the strategy of using platelet reactivity to delay surgery has been studied:
●In a prospective study of patients undergoing elective CABG, patients who were not taking clopidogrel prior to surgery were compared to patients who recently discontinued clopidogrel [20]. In the group of patients who discontinued clopidogrel, surgery was scheduled (ie, surgery within one day, delayed three to five days, or delayed at least five days) according to the severity of platelet inhibition as measured by thromboelastography. The mean waiting period for CABG was 2.7 days from thromboelastography testing, which is shorter than the usual 5 to 7 day waiting period recommended after discontinuation of clopidogrel. The two groups did not have significant differences in chest tube drainage or the number of units of blood transfused.
Postoperative P2Y12 management — For patients who had CABG and have an ongoing indication for P2Y12 inhibitor treatment (ie, recent acute coronary syndrome [ACS] or percutaneous coronary intervention in the last 12 months), some of our experts prescribe a P2Y12 inhibitor after CABG and others do not.
Observational studies in patients with recent ACS and revascularization with CABG suggest that resuming P2Y12 therapy as early as 10 to 30 days after CABG may result in a long-term clinical benefit. As examples:
●In a substudy from the CURE trial, 75 percent of patients who had CABG resumed clopidogrel or placebo at a median of 10 days after CABG surgery [18]. One year after surgery, the group of patients assigned to clopidogrel had a nonsignificantly lower risk of CV death, MI, and stroke (relative risk compared to placebo 0.81, 95% CI 0.59-1.12).
●A Danish registry study evaluated long-term outcomes in 945 patients who had CABG surgery within 180 days of a myocardial infarction and who claimed a prescription for clopidogrel within 30 days after discharge from CABG surgery [21]. At a mean follow-up of 466 days after CABG surgery, patients who received clopidogrel had a lower risk of death or recurrent myocardial infarction than propensity-matched controls who did not receive clopidogrel (4.0 versus 6.0 percent in the control group; hazard ratio 0.67, 95% CI 0.44-1.00).
There is some evidence to suggest that clopidogrel therapy for up to one year after off-pump CABG in stable patients, in addition to aspirin, may decrease the rate of vein graft occlusion [11,22,23]. Some of our contributors prescribe clopidogrel in addition to aspirin for one year after off-pump surgery in stable patients while others do not.
Beta blockers — In patients undergoing coronary artery bypass graft surgery (CABG), we start or continue beta blocker therapy prior to surgery to reduce the risk of atrial fibrillation. Further details on the use of beta blockers for prevention of atrial fibrillation can be found elsewhere. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation and complications'.)
Preoperative beta blocker therapy does not appear to reduce the risk of mortality in patients undergoing CABG. A 2014 review of patients who underwent CABG in the United States between 2008 and 2012 found no mortality benefit [24]. In this propensity-matched analysis of 138,542 individuals undergoing elective CABG, the rate of operative mortality between those who did and did not receive preoperative beta blockers within 24 hours of surgery was similar (1.1 versus 1.2 percent; odds ratio 0.96, 95% CI 0.87-1.06). The risk of permanent stroke was also similar (0.97 versus 0.98 percent; odds ratio 0.99, 95% CI 0.89-1.10).
Statins — There is a long-term mortality benefit from statin therapy in patients with coronary heart disease, including those who undergo coronary artery bypass graft surgery (CABG). Thus, most patients referred for CABG will be receiving a statin. (See "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".)
For patients who have not started statin therapy prior to CABG, the role of initiating statin therapy in the perioperative period to prevent atrial fibrillation is discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery".)
Angiotensin converting enzyme inhibitors — The optimal use of angiotensin converting enzyme (ACE) inhibitors around the time of coronary artery bypass graft surgery (CABG) is not well established. Many patients undergoing CABG are taking long-term ACE inhibitors. We believe it is reasonable to continue ACE inhibitor after CABG in such patients who are hemodynamically stable.
It has been postulated that ACE inhibitors might improve outcomes at the time of CABG as the renin-angiotensin-aldosterone system is hyperactive during and after cardiopulmonary bypass (CPB). This hyperactivity is thought to be a mediator of microvascular injury and a trigger of endothelial dysfunction. (See "Pharmacologic therapy of heart failure with reduced ejection fraction: Mechanisms of action", section on 'ACE inhibitors'.)
Some studies of perioperative ACE inhibitor use have shown improved outcomes [25,26] while others have demonstrated worse outcomes [27]. Reports of intraoperative hypotension/vasoplegia in patients taking ACE inhibitors have led to the widespread practice of not performing elective surgery unless the medication had been held for a number of days [28,29].
The potential role of ACE inhibitor was addressed in a prospective, observational study of 4224 patients undergoing CABG with CPB [30]. In this study, four groups of patients were identified: ACE inhibitor before and after surgery (continuation), ACE inhibitor before but not after surgery (withdrawal), no ACE inhibitor at any time (never), and no ACE inhibitor before but ACE inhibitor after CABG (addition). The percent of patients in each group were 21.7, 21.8, 48.4, and 8.1, respectively. ACE inhibitor was generally held the day before CABG; the decision to start (and the timing of) therapy was at the discretion of the managing physician.
The following findings were noted for the primary composite outcome of in-hospital death, cardiovascular event (heart failure or myocardial infarction), cerebrovascular event, or renal event:
●The primary outcomes occurred in 12.8, 28.1, 14.1, and 11.6 percent of cases, respectively.
●The adjusted odds ratio (OR) comparing the following pairs of groups were:
•Continuation versus never: 0.69, 95% CI 0.52-0.91
•Continuation versus withdrawal: 0.50, 95% CI 0.38-0.66.
•Addition versus never: 0.56, 95% CI 0.38-0.84
●No differences in in-hospital mortality and cerebral events were seen.
We and others are concerned about the limitations of this observational study, including multiple potential sources of bias and the inability to extrapolate to other patient groups, such as those undergoing valve surgery or off-pump CABG [31]. Until further evidence is available to support the findings of this study, we believe it is reasonable to continue ACE inhibitor after CABG in hemodynamically stable patients taking this therapy before surgery.
OTHER THERAPIES TO PREVENTION ADVERSE OUTCOMES
Glycemic control — Most clinicians accept that prevention of uncontrolled hyperglycemia in critically ill patients, including those who have undergone coronary artery bypass graft surgery (CABG), is a desirable intervention. However, the optimal blood glucose range is controversial [32]. Numerous clinical trials have compared different ranges of blood glucose in various populations of critically ill patients, including patients who have undergone CABG. This issue is discussed separately. (See "Glycemic control in critically ill adult and pediatric patients".)
The 2015 American Heart Association Scientific Statement on “Secondary Prevention after Coronary Artery Bypass Graft Surgery” recommended that striving to achieve an HBA1c of 7 percent is a reasonable goal for most patients after CABG [33].
Glucocorticoid therapy — Cardiopulmonary bypass initiates a systemic inflammatory response and glucocorticoid therapy is effective in lessening this response; thus, a potential role for routine preoperative glucocorticoid has been postulated [34]. Based on the totality of evidence presented below, including no improvement in mortality and a worsening in hyperglycemia, we do not recommend the routine preoperative use of glucocorticoids, except for patients who are receiving them chronically.
While early meta-analyses of small, randomized trials found a lower rate of postoperative atrial fibrillation (AF) with prophylactic glucocorticoid use, two subsequent large, randomized trials have not found a lower risk of AF or a lower risk of death [34-36]. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Ineffective or possibly effective therapies'.) The DECS trial randomly assigned 4494 cardiac surgery patients to a single, intraoperative dose of dexamethasone or placebo and found no significant difference in the risk of the composite end point of death, myocardial infarction, stroke, renal failure, or respiratory failure at 30 days [37]. The SIRS trial randomly assigned 7507 patients undergoing cardiac surgery to receive either high-dose methylprednisolone or placebo and found no difference in the risk of death (4 versus 5 percent, respectively) or a combined end point of death and major morbidity (24 percent in both groups) at 30 days [38].
Others have interpreted the data differently and made weak recommendations to use them in patients undergoing cardiopulmonary bypass surgery [39].
Antifibrinolytic agents — In selected patients, antifibrinolytic agents such as aminocaproic acid and tranexamic acid can reduce the amount of blood loss and the need for blood transfusions. The use of these drugs is discussed separately. (See "Blood management and anticoagulation for cardiopulmonary bypass", section on 'Antifibrinolytic administration'.)
Antimicrobial prophylaxis — The role of antimicrobial prophylaxis to prevent surgical site infection in patients undergoing CABG is discussed elsewhere. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Cardiac surgery'.)
Dexmedetomidine — There is some evidence to support the use of dexmedetomidine in patients undergoing cardiac surgery. The drug is a highly selective, centrally acting, alpha-2-agonist with anxiolytic, sedative, and analgesic effects. It is used for initial sedation of mechanically ventilated patients for up to 24 hours and has been used in transitioning cardiac surgical patients from the operating room to the intensive care unit. (See "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects", section on 'Dexmedetomidine'.)
Based on evidence suggesting that clonidine, another alpha-2 agonist, reduces the rate of some postoperative complications in cardiac surgical cases and that dexmedetomidine has a similar effect in noncardiac surgical cases [40,41], a single center observational study compared outcomes in 568 individuals undergoing cardiac surgery who received dexmedetomidine and 566 who did not [42]. After adjustment for differences between the groups, dexmedetomidine use reduced in-hospital (1.23 versus 4.59 percent; adjusted odds ratio [AOR] 0.34, 95% CI 0.192-0.614), 30-day (1.76 versus 4.12; AOR 0.39, 95% CI 0.226-0.665), and one-year (3.17 versus 7.95; AOR 0.47; 95% CI 0.312-0.701) mortality. The risk of cardiovascular complications was also significantly reduced. A second retrospective, observational study of 724 coronary artery bypass graft surgery patients made similar observations [43].
THERAPIES TO PREVENT REPERFUSION INJURY
Pyridoxal 5'-phosphate monohydrate — Pyridoxal 5'-phosphate monohydrate (MC-1), a naturally occurring metabolite of pyridoxine (vitamin B6), prevents cellular calcium overload after ischemia driven reperfusion injury [44,45]. Despite modest evidence for clinical benefit in a phase 2 trial, MC-1 did not reduce the composite end point of cardiovascular death or nonfatal myocardial infarction (MI) compared to placebo in the MEND-CABG II trial of over 3000 moderate to high risk coronary artery bypass graft surgery (CABG) patients undergoing cardiopulmonary bypass [46].
Acadesine — Intraoperative ischemia with reperfusion injury is an important cause of myocardial infarction, left ventricular systolic dysfunction, and death in patients undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention. (See "Reperfusion injury of the heart".)
Ischemic preconditioning is a potential therapy to reduce the severity of reperfusion injury and adenosine has been shown to be a facilitator of ischemic preconditioning. (See "Myocardial ischemic conditioning: Pathogenesis", section on 'Ischemic preconditioning' and "Myocardial ischemic conditioning: Pathogenesis", section on 'Adenosine'.)
While the administration of adenosine during CABG has not been shown to be beneficial, acadesine, an adenosine-regulating agent that increases intracellular levels of adenosine, reduced the rate of perioperative myocardial infarction (MI) and death in a 1997 meta-analysis of five relatively small randomized trials [47]. However, since the late 1990s, perioperative mortality and non-fatal cardiovascular events have fallen by up to 40 percent, probably attributable to improvements in perioperative management and in myocardial protection techniques. Thus, we feel that the findings in this meta-analysis may not apply to patients cared for more recently.
The RED-CABG trial, which randomly assigned intermediate- to high-risk patients undergoing nonemergency CABG to either perioperative acadesine or placebo, was designed to better evaluate the efficacy of acadesine [48]. The trial was stopped after enrollment of 3080 of the originally projected 7500 patients, as the results of a prespecified futility analysis found no difference in the rate (approximately 5 percent in both groups) of the primary composite outcome of all-cause mortality, nonfatal stroke, or need for mechanical support for severe left ventricular dysfunction.
CARDIAC REHABILITATION — The 2015 American Heart Association Scientific Statement on “Secondary Prevention after Coronary Artery Bypass Graft Surgery” recommended referral to a cardiac rehabilitation program for all patients [33]. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Indications'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Coronary artery bypass graft surgery".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Coronary artery bypass graft surgery (Beyond the Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)")
●Basics topic (see "Patient education: Coronary artery bypass graft surgery (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Aspirin – All patients with cardiovascular disease (CVD) require life-long aspirin to prevent ischemic cardiovascular events as discussed separately. (See "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease".)
For most patients already taking aspirin, we suggest continuing aspirin up to the day of coronary artery bypass graft surgery (CABG) (Grade 2C). (See 'Preoperative aspirin' above.)
After CABG, we initiate or resume aspirin therapy. We suggest starting aspirin six hours after surgery or after extubation, whichever comes first (Grade 2C). (See 'Aspirin' above.)
●P2Y12 inhibitors – In patients who are taking a P2Y12 inhibitor (eg, clopidogrel, ticagrelor) and are scheduled for CABG, we suggest discontinuing the P2Y12 inhibitor ≥5 days prior to surgery (Grade 2C). (See 'Preoperative P2Y12 management' above.)
The benefit of long-term P2Y12 inhibitor therapy after CABG is unclear. Some of our contributors resume a P2Y12 inhibitor after CABG, while others do not. (See 'Postoperative P2Y12 management' above.)
●Beta blockers – Beta blockers in the perioperative period have been shown to prevent atrial fibrillation and are routinely used after CABG, as discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation and complications'.)
●Statins – There is a long-term mortality benefit from statin therapy in patients with coronary heart disease, including those who undergo CABG. Thus, most patients referred for CABG will be receiving a statin, as discussed separately. (See "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".)
For patients who have not started statin therapy prior to CABG, the role of initiating statin therapy in the perioperative period to prevent atrial fibrillation is discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery".)
ACKNOWLEDGMENT — The UpToDate editorial staff would like to thank Dr. Julian M. Aroesty for his contributions as an author to prior versions of this topic review.
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