Medical therapy to prevent complications after coronary artery bypass graft surgery
- Sary Aranki, MD
Sary Aranki, MD
- Associate Professor of Surgery
- Harvard Medical School
- Julian M Aroesty, MD
Julian M Aroesty, MD
- Clinical Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
- Guy S Reeder, MD
Guy S Reeder, MD
- Section Editor — Coronary Disease
- Professor of Medicine
- Mayo Medical School
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 (PCI) should be considered in several subgroups. (See "Stable ischemic heart disease: 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".)
Aspirin should be administered to all patients without a contraindication who have cardiovascular disease. (See "Aspirin for the secondary prevention of cardiovascular disease", section on 'Summary and recommendations'.)
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) . 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.
- Collaborative overview of randomised trials of antiplatelet therapy--II: Maintenance of vascular graft or arterial patency by antiplatelet therapy. Antiplatelet Trialists' Collaboration. BMJ 1994; 308:159.
- Goldman S, Copeland J, Moritz T, et al. Starting aspirin therapy after operation. Effects on early graft patency. Department of Veterans Affairs Cooperative Study Group. Circulation 1991; 84:520.
- Sethi GK, Copeland JG, Goldman S, et al. Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting. Department of Veterans Affairs Cooperative Study on Antiplatelet Therapy. J Am Coll Cardiol 1990; 15:15.
- Myles PS, Smith JA, Forbes A, et al. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med 2016; 374:728.
- Bybee KA, Powell BD, Valeti U, et al. Preoperative aspirin therapy is associated with improved postoperative outcomes in patients undergoing coronary artery bypass grafting. Circulation 2005; 112:I286.
- Dacey LJ, Munoz JJ, Johnson ER, et al. Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients. Ann Thorac Surg 2000; 70:1986.
- Jacob M, Smedira N, Blackstone E, et al. Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation 2011; 123:577.
- Fuster V, Chesebro JH. Role of platelets and platelet inhibitors in aortocoronary artery vein-graft disease. Circulation 1986; 73:227.
- Mangano DT, Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med 2002; 347:1309.
- Topol EJ. Aspirin with bypass surgery--from taboo to new standard of care. N Engl J Med 2002; 347:1359.
- Henn V, Slupsky JR, Gräfe M, et al. CD40 ligand on activated platelets triggers an inflammatory reaction of endothelial cells. Nature 1998; 391:591.
- Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation 2015; 131:927.
- Gavaghan TP, Gebski V, Baron DW. Immediate postoperative aspirin improves vein graft patency early and late after coronary artery bypass graft surgery. A placebo-controlled, randomized study. Circulation 1991; 83:1526.
- Sun JC, Crowther MA, Warkentin TE, et al. Should aspirin be discontinued before coronary artery bypass surgery? Circulation 2005; 112:e85.
- Cannon CP, Mehta SR, Aranki SF. Balancing the benefit and risk of oral antiplatelet agents in coronary artery bypass surgery. Ann Thorac Surg 2005; 80:768.
- Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.
- Ferraris VA, Ferraris SP, Moliterno DJ, et al. The Society of Thoracic Surgeons practice guideline series: aspirin and other antiplatelet agents during operative coronary revascularization (executive summary). Ann Thorac Surg 2005; 79:1454.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on August 24, 2006).
- Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation 2004; 110:1202.
- Sørensen R, Abildstrøm SZ, Hansen PR, et al. Efficacy of post-operative clopidogrel treatment in patients revascularized with coronary artery bypass grafting after myocardial infarction. J Am Coll Cardiol 2011; 57:1202.
- Ferguson TB Jr, Coombs LP, Peterson ED, Society of Thoracic Surgeons National Adult Cardiac Surgery Database. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA 2002; 287:2221.
- Brinkman W, Herbert MA, O'Brien S, et al. Preoperative β-blocker use in coronary artery bypass grafting surgery: national database analysis. JAMA Intern Med 2014; 174:1320.
- Qaseem A, Humphrey LL, Chou R, et al. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2011; 154:260.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Liakopoulos OJ, Kuhn EW, Slottosch I, et al. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2012; :CD008493.
- Kuhn EW, Slottosch I, Wahlers T, Liakopoulos OJ. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2015; :CD008493.
- Zheng Z, Jayaram R, Jiang L, et al. Perioperative Rosuvastatin in Cardiac Surgery. N Engl J Med 2016; 374:1744.
- Oosterga M, Voors AA, Pinto YM, et al. Effects of quinapril on clinical outcome after coronary artery bypass grafting (The QUO VADIS Study). QUinapril on Vascular Ace and Determinants of Ischemia. Am J Cardiol 2001; 87:542.
- Kjøller-Hansen L, Steffensen R, Grande P. The Angiotensin-converting Enzyme Inhibition Post Revascularization Study (APRES). J Am Coll Cardiol 2000; 35:881.
- Miceli A, Capoun R, Fino C, et al. Effects of angiotensin-converting enzyme inhibitor therapy on clinical outcome in patients undergoing coronary artery bypass grafting. J Am Coll Cardiol 2009; 54:1778.
- Tuman KJ, McCarthy RJ, O'Connor CJ, et al. Angiotensin-converting enzyme inhibitors increase vasoconstrictor requirements after cardiopulmonary bypass. Anesth Analg 1995; 80:473.
- Oh YJ, Lee JH, Nam SB, et al. Effects of chronic angiotensin II receptor antagonist and angiotensin-converting enzyme inhibitor treatments on neurohormonal levels and haemodynamics during cardiopulmonary bypass. Br J Anaesth 2006; 97:792.
- Drenger B, Fontes ML, Miao Y, et al. Patterns of use of perioperative angiotensin-converting enzyme inhibitors in coronary artery bypass graft surgery with cardiopulmonary bypass: effects on in-hospital morbidity and mortality. Circulation 2012; 126:261.
- Barodka V, Nyhan D, Berkowitz D. About fACE: perioperative use of angiotensin-converting enzyme inhibitors. Circulation 2012; 126:249.
- Whitlock RP, Chan S, Devereaux PJ, et al. Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials. Eur Heart J 2008; 29:2592.
- Ho KM, Tan JA. Benefits and risks of corticosteroid prophylaxis in adult cardiac surgery: a dose-response meta-analysis. Circulation 2009; 119:1853.
- Dieleman JM, van Paassen J, van Dijk D, et al. Prophylactic corticosteroids for cardiopulmonary bypass in adults. Cochrane Database Syst Rev 2011; :CD005566.
- Dieleman JM, Nierich AP, Rosseel PM, et al. Intraoperative high-dose dexamethasone for cardiac surgery: a randomized controlled trial. JAMA 2012; 308:1761.
- Whitlock RP, Devereaux PJ, Teoh KH, et al. Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): a randomised, double-blind, placebo-controlled trial. Lancet 2015; 386:1243.
- Yellon DM, Hausenloy DJ. Myocardial reperfusion injury. N Engl J Med 2007; 357:1121.
- Tardif JC, Carrier M, Kandzari DE, et al. Effects of pyridoxal-5'-phosphate (MC-1) in patients undergoing high-risk coronary artery bypass surgery: results of the MEND-CABG randomized study. J Thorac Cardiovasc Surg 2007; 133:1604.
- MEND-CABG II Investigators, Alexander JH, Emery RW Jr, et al. Efficacy and safety of pyridoxal 5'-phosphate (MC-1) in high-risk patients undergoing coronary artery bypass graft surgery: the MEND-CABG II randomized clinical trial. JAMA 2008; 299:1777.
- Mangano DT. Effects of acadesine on myocardial infarction, stroke, and death following surgery. A meta-analysis of the 5 international randomized trials. The Multicenter Study of Perioperative Ischemia (McSPI) Research Group. JAMA 1997; 277:325.
- Newman MF, Ferguson TB, White JA, et al. Effect of adenosine-regulating agent acadesine on morbidity and mortality associated with coronary artery bypass grafting: the RED-CABG randomized controlled trial. JAMA 2012; 308:157.
- Nishina K, Mikawa K, Uesugi T, et al. Efficacy of clonidine for prevention of perioperative myocardial ischemia: a critical appraisal and meta-analysis of the literature. Anesthesiology 2002; 96:323.
- Wijeysundera DN, Naik JS, Beattie WS. Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: a meta-analysis. Am J Med 2003; 114:742.
- Ji F, Li Z, Nguyen H, et al. Perioperative dexmedetomidine improves outcomes of cardiac surgery. Circulation 2013; 127:1576.
- Ji F, Li Z, Young N, et al. Perioperative dexmedetomidine improves mortality in patients undergoing coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2014; 28:267.
- Preoperative aspirin
- Postoperative aspirin
- Aspirin summary
- PLATELET P2Y12 RECEPTOR BLOCKER THERAPY
- BETA BLOCKERS
- GLYCEMIC CONTROL
- ANGIOTENSIN CONVERTING ENZYME INHIBITORS
- GLUCOCORTICOID THERAPY
- ANTIFIBRINOLYTIC AGENTS
- PYRIDOXAL 5'-PHOSPHATE MONOHYDRATE
- CARDIAC REHABILITATION
- INFORMATION FOR PATIENTS