AHA Scientific Statement on Prevention Management After CABG | Ten Points to Remember

Kulik A, Ruel M, Jneid H, et al., on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia.
Secondary Prevention After Coronary Artery Bypass Graft Surgery: A Scientific Statement From the American Heart Association. Circulation 2015;Feb 9:[Epub ahead of print].

The following are 10 points to remember about secondary prevention after coronary artery bypass graft surgery (CABG):

  1. Aspirin 81-325 mg/day is recommended for patients undergoing CABG, preoperatively and within 6 hours after surgery, to reduce graft occlusion and future cardiac events. Aspirin should be continued indefinitely unless contraindications arise. It is reasonable to prescribe clopidogrel 75 mg/day if patients are intolerant or allergic to aspirin. For patients who undergo off-pump CABG, dual antiplatelet therapy is recommended for 1 year (aspirin 81-162 mg/day with clopidogrel 75 mg/day). Among patients who have recently experienced an acute coronary syndrome (ACS) event, it is reasonable to administer aspirin and either prasugrel or ticagrelor, as opposed to clopidogrel. Among patients without a recent ACS event, it is reasonable to prescribe dual antiplatelet therapy with aspirin and clopidogrel.
  2. Warfarin is not recommended for reduction of graft occlusion; rather, use of warfarin is recommended when patients have indications such as atrial fibrillation or a mechanical prosthetic valve.
  3. Statin therapy is recommended for all CABG patients unless a contraindication is present. A high-intensity dose is recommended among patients <75 years of age, with a moderate-intensity dose for those who are intolerant of higher doses or at greater risk for drug–drug interactions.
  4. Beta-blockers are recommended, starting perioperatively, to reduce the risk of postoperative atrial fibrillation. Patients with a history of myocardial infarction and left ventricular dysfunction are also recommended for beta-blocker therapy.
  5. For management of hypertension, a goal of <140/85 mm Hg appears reasonable, although this target has not been evaluated formally in CABG populations.
  6. Measurement of glycated hemoglobin (HgA1c and fasting glucose is appropriate in patients scheduled for CABG. A goal HgA1c of <7% is reasonable for such patients.
  7. Smoking cessation is a Class I recommendation. Use of nicotine replacement therapy, bupropion, and varenicline in addition to smoking cessation counseling is reasonable for CABG patients who currently smoke.
  8. Cardiac rehabilitation is a Class I recommendation for all patients after CABG. Referral should be placed early postoperatively for all patients.
  9. Given the high rates of depression after surgery, it is reasonable to screen for depression after CABG.
  10. Annual influenza vaccination has been shown to reduce death and hospitalization for coronary artery disease among patients with heart disease. Therefore, annual vaccination is recommended for all CABG patients without contraindications.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Hypertension

Keywords: Secondary Prevention, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Coronary Artery Disease, Aspirin, Atrial Fibrillation, Counseling, Depression, Hemoglobin A, Glycosylated, Hypertension, Nicotine, Smoking Cessation, Tobacco Use Cessation Products, Warfarin, Influenza, Human, Vaccination, Adrenergic beta-Antagonists

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