What are the 2015 AHA guidelines for secondary prevention after coronary artery bypass grafting (CABG)?

Updated: May 07, 2019
  • Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang, MD  more...
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Answer

In 2015, the AHA published a scientific statement on secondary prevention after CABG with the following recommendations [131] :

  • Administer aspirin within 6 hours after CABG in doses of 81 to 325 mg daily. Continue aspirin indefinitely to reduce graft occlusion and adverse cardiac events. (Class I, level of evidence: A)

  • After off-pump CABG, administer dual antiplatelet therapy (DAPT)  for 1 year with combined aspirin (81-162 mg daily) and clopidogrel (75 mg daily) to reduce graft occlusion. (Class I, level of evidence: A)

  • After CABG, clopidogrel 75 mg daily is a reasonable alternative for patients who cannot take aspirin. (Class IIa, level of evidence: C)

  • In patients who present with acute coronary syndrome (ACS), it is reasonable to administer combination antiplatelet therapy with aspirin and either prasugrel or ticagrelor (preferred over clopidogrel) (Class IIa, level of evidence: B)

  • After on-pump CABG, combination therapy with aspirin and clopidogrel for 1 year may be considered in patients without recent ACS, but the benefits are not well established. (Class IIb, level of evidence: A)

  • Warfarin should not be routinely prescribed after CABG for graft patency unless patients have other indications for long-term antithrombotic therapy (such as atrial fibrillation [AF], venous thromboembolism, or a mechanical prosthetic valve). (Class III, level of evidence: A)

  • Antithrombotic alternatives to warfarin (dabigatran, apixaban, rivaroxaban) should not be routinely administered after CABG. (Class III, level of evidence: C)

  • CABG patients should receive statin therapy, starting in the preoperative period and restarting early after surgery. (Class I, level of evidence: A)

  • Administer postoperative high-intensity statin therapy (atorvastatin 40-80 mg, rosuvastatin 20-40 mg) to all CABG patients younger than 75 years. (Class I, level of evidence: A)

  • Administer moderate-intensity statin therapy for those patients who are intolerant of high-intensity statin therapy and for those at greater risk for drug-drug interactions (ie, patients aged >75 years). (Class I, level of evidence: A)

  • Pre- or post-CABG discontinuation of statin therapy is not recommended unless patients have adverse reactions to therapy. (Class III, level of evidence: B)

  • Administer beta-blockers as soon as possible around the time of CABG, in the absence of contraindications, to reduce the risk of postoperative AF and to facilitate blood pressure (BP) control early after surgery. (Class I, level of evidence: A)

  • Administer angiotensin-converting enzyme (ACE) inhibitor therapy after CABG for patients with recent MI, left ventricular (LV) dysfunction, diabetes mellitus, and chronic kidney disease. Carefully consider the patient's renal function in determining the timing of postoperative ACE inhibitor initiation and dose selection. (Class I, level of evidence: B)

  • Routine ACE inhibitor therapy is not recommended early after CABG among patients without a history of recent MI, LV dysfunction, diabetes mellitus, or chronic kidney disease, because it may lead to more harm than benefit and an unpredictable BP response. (Class III, level of evidence: B)

  • Cardiac rehabilitation is recommended for all patients after CABG, with the referral ideally performed early during the surgical hospital stay. (Class I, level of evidence: A)


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