Secondary Prevention After Coronary Artery Bypass Graft Surgery: A Scientific Statement From the American Heart Association
Circulation 2015;131:927-64
Antiplatelet Therapy β-Blocker Therapy Diabetes Mellitus
1. Aspirin should be administered preoperatively and within 6 hours after CABG in 1. All CABG patients should be prescribed perioperative β-blocker therapy to 1. Striving to achieve an HbA1c of 7% is a reasonable goal for most patients after
doses of 81 to 325 mg daily. It should then be continued indefinitely to reduce prevent postoperative AF, ideally starting before surgery, unless contraindicated CABG to reduce microvascular diabetic complications and macrovascular
graft occlusion and adverse cardiac events (Class I; Level of Evidence A). (i.e., bradycardia, severe reactive airway disease) (Class I; Level of Evidence A). cardiovascular disease (Class IIa; Level of Evidence B).
2. After off-pump CABG, dual antiplatelet should be administered for 1 year with 2. CABG patients with a history of MI should be prescribed β-blocker therapy
combined aspirin (81-162 mg daily) and clopidogrel 75 mg daily to reduce graft unless contraindicated (Class I; Level of Evidence A).
occlusion (Class I; Level of Evidence A). 3. CABG patients with LV dysfunction should be prescribed β-blocker therapy
3. Clopidogrel 75 mg daily is a reasonable alternative after CABG for patients who (bisoprolol, sustained-release metoprolol succinate, or carvedilol), unless Smoking Cessation
are intolerant of or allergic to aspirin. It is reasonable to continue it indefinitely contraindicated (Class I; Level of Evidence B).
(Class IIa; Level of Evidence C). 4. Chronic β-blocker therapy for hypertension treatment after CABG (in the 1. Smoking cessation is critical, and counseling should be offered to all patients
4. In patients who present with acute coronary syndrome, it is reasonable to absence of prior MI or LV dysfunction) may be considered, but other who smoke, during and after hospitalization for CABG, to help improve both
administer combination antiplatelet therapy after CABG with aspirin and either antihypertensive therapies may be more effective and more easily tolerated short- and long-term clinical outcomes after surgery (Class I; Level of Evidence
prasugrel or ticagrelor (preferred over clopidogrel), although prospective clinical (Class IIb; Level of Evidence B). A).
trial data from CABG populations are not yet available (Class IIa; Level of 2. It is reasonable to offer nicotine replacement therapy, bupropion, and varenicline
Evidence B). as adjuncts to smoking cessation counseling for stable CABG patients after
5. As sole antiplatelet therapy after CABG, it is reasonable to consider a higher hospital discharge (Class IIa; Level of Evidence B).
aspirin dose (325 mg daily) rather than a lower aspirin dose (81 mg daily), Hypertension Management 3. Nicotine replacement therapy, bupropion, and varenicline may be considered as
presumably to prevent aspirin resistance, but the benefits are not well established adjuncts to smoking cessation counseling during CABG hospitalization, but their
(Class IIa; Level of Evidence A). 1. β-Blockers should be administered as soon as possible after CABG, in the use should be carefully considered on an individualized basis (Class IIb; Level of
6. Combination therapy with both aspirin and clopidogrel for 1 year after on-pump absence of contraindications, to reduce the risk of postoperative AF and to Evidence B).
CABG may be considered in patients without recent acute coronary syndrome, facilitate BP control early after surgery (Class I; Level of Evidence A).
but the benefits are not well established (Class IIb; Level of Evidence Level A). 2. ACE inhibitor therapy should be administered after CABG for patients with
recent MI, LV dysfunction, diabetes mellitus, and chronic kidney disease, with Cardiac Rehabilitation
careful consideration of renal function in determining the timing of initiation and
dose selection after surgery (Class I; Level of Evidence B). 1. CR is recommended for all patients after CABG, with the referral ideally
Antithrombotic Therapy 3. With the use of antihypertensive medications, it is reasonable to target a BP goal performed early postoperatively during the surgical hospital stay (Class I; Level
of <140/85 mmHg after CABG; however the ideal BP target has not been of Evidence A).
1. Warfarin should not be routinely prescribed after CABG for graft patency unless formally evaluated in the CABG population (Class IIa; Level of Evidence B).
patients have other indications for long-term antithrombotic therapy (such as AF, 4. It is reasonable to add a calcium channel blocker or a diuretic agent as an
venous thromboembolism, or a mechanical prosthetic valve) (Class III; Level of additional therapeutic choice if the BP goal has not yet been achieved in the
Evidence A). perioperative period after CABG despite β-blocker therapy and ACE inhibitor Mental Health and Cognitive Decline
2. Antithrombotic alternatives to warfarin (dabigatran, apixaban, rivaroxaban) therapy as appropriate (Class IIa; Level of Evidence B).
should not be routinely administered early after CABG until additional safety 5. In the absence of prior MI or LV dysfunction, antihypertensive therapies other 1. For patients after CABG, it is reasonable to screen for depression in
data have accrued (Class III; Level of Evidence C). than β-blockers should be considered for chronic hypertension management collaboration with a primary care physician and a mental health specialist (Class
long-term after CABG (Class IIb; Level of Evidence B). IIa; Level of Evidence B).
6. Routine ACE inhibitor therapy is not recommended early after CABG among 2. Cognitive behavior therapy or collaborative care for patients with clinical
patients who do not have a history of recent MI, LV dysfunction, diabetes depression after CABG can be beneficial to reduce depression (Class IIa; Level
Lipid Management
mellitus, or chronic kidney disease because it may lead to more harm than of Evidence B).
benefit and an unpredictable BP response (Class III; Level of Evidence B).
1. Unless contraindicated, all CABG patients should receive statin therapy,
starting in the preoperative period and restarting early after surgery (Class I;
Level of Evidence A). Obesity and Metabolic Syndrome
2. High-intensity statin therapy (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) Previous MI and LV Dysfunction
should be administered after surgery to all CABG patients <75 years of age 1. The assessment of central distribution of fat is reasonable in CABG patients by
(Class I; Level of Evidence A). 1. In the absence of contraindications, β-blockers (bisoprolol, carvedilol, and measuring waist and hip circumference and calculating waist-to-hip ratio, even if
3. Moderate-intensity statin therapy should be administered after CABG for those sustained-release metoprolol succinate) are recommended after CABG to all the BMI is within normal limits (Class IIa; Level of Evidence C).
patients who are intolerant of high-intensity statin therapy and for those at patients with reduced EF (<40%), especially among patients with heart failure or 2. Bariatric surgery may be considered for CABG patients with a BMI >35 kg/m2
greater risk for drug-drug interactions (i.e., patients >75 years of age) (Class I; those with prior MI (Class I; Level of Evidence A). if lifestyle interventions have already been attempted without meaningful weight
Level of Evidence A). 2. In the absence of contraindications, ACE inhibitor or ARB therapy (if the patient loss (Class IIb; Level of Evidence C).
4. Discontinuation of statin therapy is not recommended before or after CABG is ACE inhibitor intolerant) is recommended after CABG to all patients with LV
unless patients have adverse reactions to therapy (Class III; Level of Evidence dysfunction (EF <40%) or previous MI (Class I; Level of Evidence B).
B). 3. In the absence of contraindications, it is reasonable to add an aldosterone
antagonist (on top of β-blocker and ACE inhibitor therapy) after CABG for Vitamins and Supplements
patients with LV dysfunction (EF <35%) who have class NYHA class II to IV
heart failure symptoms (Class IIa; Level of Evidence B). 1. Vitamin supplementation in patients with specific vitamin deficiencies may be
Vaccination considered for patients undergoing CABG, but the effectiveness is not well
4. Among patients with LV dysfunction (EF <35%), ICD therapy is not
recommended for the prevention of sudden cardiac death after CABG until 3 established (Class IIb; Level of Evidence C).
1. Annual influenza vaccination should be offered to all CABG patients, unless 2. Supplementation with omega-3 fatty acids and anti-oxidant vitamins may be
months of postoperative goal-directed medical therapy has been provided and
contraindications exist (Class I; Level of Evidence B). considered to prevent postoperative AF after CABG, but additional clinical
persistent LV dysfunction has been confirmed (Class III; Level of Evidence A).
studies are warranted before routine use of antioxidant vitamins can be
recommended (Class IIb; Level of Evidence A).
Complied by Arden Barry, BSc, BSc(Pharm), PharmD, ACPR for the CSHP BC Branch AGM November 2015
Circulation 2015;131:927-64
Antiplatelet Therapy β-Blocker Therapy Diabetes Mellitus
1. Aspirin should be administered preoperatively and within 6 hours after CABG in 1. All CABG patients should be prescribed perioperative β-blocker therapy to 1. Striving to achieve an HbA1c of 7% is a reasonable goal for most patients after
doses of 81 to 325 mg daily. It should then be continued indefinitely to reduce prevent postoperative AF, ideally starting before surgery, unless contraindicated CABG to reduce microvascular diabetic complications and macrovascular
graft occlusion and adverse cardiac events (Class I; Level of Evidence A). (i.e., bradycardia, severe reactive airway disease) (Class I; Level of Evidence A). cardiovascular disease (Class IIa; Level of Evidence B).
2. After off-pump CABG, dual antiplatelet should be administered for 1 year with 2. CABG patients with a history of MI should be prescribed β-blocker therapy
combined aspirin (81-162 mg daily) and clopidogrel 75 mg daily to reduce graft unless contraindicated (Class I; Level of Evidence A).
occlusion (Class I; Level of Evidence A). 3. CABG patients with LV dysfunction should be prescribed β-blocker therapy
3. Clopidogrel 75 mg daily is a reasonable alternative after CABG for patients who (bisoprolol, sustained-release metoprolol succinate, or carvedilol), unless Smoking Cessation
are intolerant of or allergic to aspirin. It is reasonable to continue it indefinitely contraindicated (Class I; Level of Evidence B).
(Class IIa; Level of Evidence C). 4. Chronic β-blocker therapy for hypertension treatment after CABG (in the 1. Smoking cessation is critical, and counseling should be offered to all patients
4. In patients who present with acute coronary syndrome, it is reasonable to absence of prior MI or LV dysfunction) may be considered, but other who smoke, during and after hospitalization for CABG, to help improve both
administer combination antiplatelet therapy after CABG with aspirin and either antihypertensive therapies may be more effective and more easily tolerated short- and long-term clinical outcomes after surgery (Class I; Level of Evidence
prasugrel or ticagrelor (preferred over clopidogrel), although prospective clinical (Class IIb; Level of Evidence B). A).
trial data from CABG populations are not yet available (Class IIa; Level of 2. It is reasonable to offer nicotine replacement therapy, bupropion, and varenicline
Evidence B). as adjuncts to smoking cessation counseling for stable CABG patients after
5. As sole antiplatelet therapy after CABG, it is reasonable to consider a higher hospital discharge (Class IIa; Level of Evidence B).
aspirin dose (325 mg daily) rather than a lower aspirin dose (81 mg daily), Hypertension Management 3. Nicotine replacement therapy, bupropion, and varenicline may be considered as
presumably to prevent aspirin resistance, but the benefits are not well established adjuncts to smoking cessation counseling during CABG hospitalization, but their
(Class IIa; Level of Evidence A). 1. β-Blockers should be administered as soon as possible after CABG, in the use should be carefully considered on an individualized basis (Class IIb; Level of
6. Combination therapy with both aspirin and clopidogrel for 1 year after on-pump absence of contraindications, to reduce the risk of postoperative AF and to Evidence B).
CABG may be considered in patients without recent acute coronary syndrome, facilitate BP control early after surgery (Class I; Level of Evidence A).
but the benefits are not well established (Class IIb; Level of Evidence Level A). 2. ACE inhibitor therapy should be administered after CABG for patients with
recent MI, LV dysfunction, diabetes mellitus, and chronic kidney disease, with Cardiac Rehabilitation
careful consideration of renal function in determining the timing of initiation and
dose selection after surgery (Class I; Level of Evidence B). 1. CR is recommended for all patients after CABG, with the referral ideally
Antithrombotic Therapy 3. With the use of antihypertensive medications, it is reasonable to target a BP goal performed early postoperatively during the surgical hospital stay (Class I; Level
of <140/85 mmHg after CABG; however the ideal BP target has not been of Evidence A).
1. Warfarin should not be routinely prescribed after CABG for graft patency unless formally evaluated in the CABG population (Class IIa; Level of Evidence B).
patients have other indications for long-term antithrombotic therapy (such as AF, 4. It is reasonable to add a calcium channel blocker or a diuretic agent as an
venous thromboembolism, or a mechanical prosthetic valve) (Class III; Level of additional therapeutic choice if the BP goal has not yet been achieved in the
Evidence A). perioperative period after CABG despite β-blocker therapy and ACE inhibitor Mental Health and Cognitive Decline
2. Antithrombotic alternatives to warfarin (dabigatran, apixaban, rivaroxaban) therapy as appropriate (Class IIa; Level of Evidence B).
should not be routinely administered early after CABG until additional safety 5. In the absence of prior MI or LV dysfunction, antihypertensive therapies other 1. For patients after CABG, it is reasonable to screen for depression in
data have accrued (Class III; Level of Evidence C). than β-blockers should be considered for chronic hypertension management collaboration with a primary care physician and a mental health specialist (Class
long-term after CABG (Class IIb; Level of Evidence B). IIa; Level of Evidence B).
6. Routine ACE inhibitor therapy is not recommended early after CABG among 2. Cognitive behavior therapy or collaborative care for patients with clinical
patients who do not have a history of recent MI, LV dysfunction, diabetes depression after CABG can be beneficial to reduce depression (Class IIa; Level
Lipid Management
mellitus, or chronic kidney disease because it may lead to more harm than of Evidence B).
benefit and an unpredictable BP response (Class III; Level of Evidence B).
1. Unless contraindicated, all CABG patients should receive statin therapy,
starting in the preoperative period and restarting early after surgery (Class I;
Level of Evidence A). Obesity and Metabolic Syndrome
2. High-intensity statin therapy (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) Previous MI and LV Dysfunction
should be administered after surgery to all CABG patients <75 years of age 1. The assessment of central distribution of fat is reasonable in CABG patients by
(Class I; Level of Evidence A). 1. In the absence of contraindications, β-blockers (bisoprolol, carvedilol, and measuring waist and hip circumference and calculating waist-to-hip ratio, even if
3. Moderate-intensity statin therapy should be administered after CABG for those sustained-release metoprolol succinate) are recommended after CABG to all the BMI is within normal limits (Class IIa; Level of Evidence C).
patients who are intolerant of high-intensity statin therapy and for those at patients with reduced EF (<40%), especially among patients with heart failure or 2. Bariatric surgery may be considered for CABG patients with a BMI >35 kg/m2
greater risk for drug-drug interactions (i.e., patients >75 years of age) (Class I; those with prior MI (Class I; Level of Evidence A). if lifestyle interventions have already been attempted without meaningful weight
Level of Evidence A). 2. In the absence of contraindications, ACE inhibitor or ARB therapy (if the patient loss (Class IIb; Level of Evidence C).
4. Discontinuation of statin therapy is not recommended before or after CABG is ACE inhibitor intolerant) is recommended after CABG to all patients with LV
unless patients have adverse reactions to therapy (Class III; Level of Evidence dysfunction (EF <40%) or previous MI (Class I; Level of Evidence B).
B). 3. In the absence of contraindications, it is reasonable to add an aldosterone
antagonist (on top of β-blocker and ACE inhibitor therapy) after CABG for Vitamins and Supplements
patients with LV dysfunction (EF <35%) who have class NYHA class II to IV
heart failure symptoms (Class IIa; Level of Evidence B). 1. Vitamin supplementation in patients with specific vitamin deficiencies may be
Vaccination considered for patients undergoing CABG, but the effectiveness is not well
4. Among patients with LV dysfunction (EF <35%), ICD therapy is not
recommended for the prevention of sudden cardiac death after CABG until 3 established (Class IIb; Level of Evidence C).
1. Annual influenza vaccination should be offered to all CABG patients, unless 2. Supplementation with omega-3 fatty acids and anti-oxidant vitamins may be
months of postoperative goal-directed medical therapy has been provided and
contraindications exist (Class I; Level of Evidence B). considered to prevent postoperative AF after CABG, but additional clinical
persistent LV dysfunction has been confirmed (Class III; Level of Evidence A).
studies are warranted before routine use of antioxidant vitamins can be
recommended (Class IIb; Level of Evidence A).
Complied by Arden Barry, BSc, BSc(Pharm), PharmD, ACPR for the CSHP BC Branch AGM November 2015
