Antiplatelet therapy.
1, Aspirin 81-325mg/d should be used preoperatively and within 6 hours postoperatively and should be continued continuously thereafter (no definite duration) to reduce graft vessel occlusion and adverse cardiac events.
2, After non-extracorporeal CABG, dual antiplatelet therapy with aspirin (81~162mg/d) and clopidogrel (75mg/d) should be used to reduce graft vessel occlusion.
3.Patients who are intolerant or allergic to aspirin can be replaced with clopidogrel (75mg/d) after surgery, and it is reasonable to continue clopidogrel (no definite duration).
4, In patients presenting with acute coronary syndrome (ACS), the postoperative use of aspirin in combination with prasugrel or tigretol (superior to the combination of clopidogrel) is reasonable, although prospective clinical data from patients with CABG are lacking.
5, The use of high-dose aspirin (325 mg/d) is superior to low-dose (81 mg/d) in postoperative monotherapy, or may prevent aspirin resistance, but the advantage is not fully substantiated.
6. Aspirin combined with clopidogrel may be considered for 1 year in patients with CABG without recent ACS, but its advantages are not fully realized.
Antithrombotic therapy.
1, Routine use of warfarin is not recommended postoperatively unless the patient has other indications for long-term antithrombotic therapy (e.g., atrial fibrillation, venous thromboembolism, placement of a prosthetic mechanical valve).
2. Routine use of other antithrombotic agents (dabigatran, apixaban, rivaroxaban) is not recommended in the early postoperative period unless additional data confirm their safety.
Lipid management.
1. Unless contraindicated, all patients with CABG should resume statin use preoperatively and early postoperatively. All patients under 75 years of age should be treated with high-intensity statins (atorvastatin 40-80 mg and resorvastatin 20-40 mg) postoperatively.
2. For patients who do not tolerate high-intensity statin therapy or who are at higher risk of drug interactions (e.g., age >75 years), medium-intensity statin therapy should be used.
3. Statins should not be discontinued before or after CABG unless patients experience adverse reactions.
Beta-blocker therapy.
1. Unless there are contraindications (e.g. bradycardia, severe airway responsive disease), all patients must be treated with beta-blockers in the perioperative period (ideally started preoperatively) to prevent postoperative atrial fibrillation.
2. Unless contraindicated, β-blockers should be used in patients with a history of myocardial infarction.
3. Unless contraindicated, β-blockers (bisoprolol, metoprolol succinate extended-release tablets, carvedilol) should be used in those with left ventricular insufficiency.
4. Long-term beta-blocker therapy can be considered for postoperative antihypertensive treatment (without a history of myocardial infarction and left ventricular insufficiency), but other antihypertensive treatments may be more effective and tolerable.
Hypertension management.
1. Unless contraindicated, beta-blockers should be used as soon as possible after surgery to prevent postoperative atrial fibrillation and control blood pressure as early as possible.
2. For patients with recent myocardial infarction, left ventricular dysfunction, diabetes mellitus, or chronic kidney disease, angiotensin-converting enzyme inhibitors (ACEIs) should be used postoperatively. Renal function should be carefully considered when determining the starting time and dose of medication.
3, The goal of postoperative antihypertensive therapy should be less than 140/85 mmHg, although there is a lack of assessment of optimal blood pressure control goals in the CABG population.
4.If the target blood pressure cannot be achieved during the postoperative perioperative period after the use of β-blockers and ACEI, calcium antagonists or diuretics may be added.
5.In patients without a history of myocardial infarction and left ventricular insufficiency, antihypertensive therapy other than β-blockers should be considered in the long-term postoperative blood pressure management.
6. For patients without a history of myocardial infarction, left ventricular insufficiency, diabetes mellitus, or chronic kidney disease, the routine use of ACEI in the early postoperative period is not recommended because the disadvantages outweigh the benefits and may also lead to unpredictable blood pressure reactions.
With a history of infarction and left ventricular insufficiency.
1, Unless contraindicated, beta-blockers (bisoprolol, metoprolol succinate extended-release tablets, carvedilol) are recommended for all patients with reduced ejection fraction (EF) (less than 40%), especially those with a history of heart failure or myocardial infarction.
2. Unless contraindicated, ACEI or angiotensin receptor antagonist (ARB, when the patient is intolerant to ACEI) is recommended postoperatively for patients with left ventricular insufficiency (EF < 40%).
3. Unless contraindicated, it is reasonable to add an aldosterone receptor antagonist to a beta-blocker and ACEI postoperatively in patients presenting with left ventricular insufficiency (EF<35%) and New York Heart Association (NYHA) cardiac function class II-IV.
4. In patients with left ventricular insufficiency (EF < 35%), the use of buried cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death is not recommended until they have received 3 months of postoperative drug therapy with a clear goal and sustained left ventricular insufficiency has been established.
Diabetes mellitus.
For most patients, postoperative glycated hemoglobin (HbA1c) levels controlled to less than 7% are reasonable to reduce microvascular and macrovascular complications.
Smoking cessation.
1, Smoking cessation is very important, and counseling should be provided to CABG patients who continue to smoke in the hospital and after discharge to improve short- and long-term clinical prognosis.
2. After patient discharge, it is reasonable to provide nicotine replacement therapy, bupropion, and varenicline based on smoking cessation counseling services for CABG patients with stable disease.
3. During the patient’s hospitalization, nicotine replacement therapy, bupropion, and varenicline may be considered on the basis of smoking cessation counseling services, but the individual’s mental health should be carefully considered.
Mental health and cognitive decline.
1, It is reasonable to work with primary care physicians and mental health professionals to screen for depression postoperatively.
2. In patients with postoperative comorbid clinical depression, cognitive behavioral therapy and combination therapy may be used to reduce depressive conditions.
Obesity and metabolic syndrome.
1, Patients should be assessed for the degree of centripetal body fat distribution (measuring waist and hip circumference and calculating waist-to-hip ratio), even if the body mass index (BMI) is normal.
2. For patients with BMI higher than 35 kg/m2, bariatric surgery should be considered if lifestyle interventions fail to achieve effective weight loss.
Vitamins and other supplements.
1, specific vitamin deficiencies can be used vitamin supplements, but the effectiveness is not completely symptomatic.
2. Omega-3 fatty acid and antioxidant vitamin supplements may be considered to prevent postoperative AF, but more clinical studies are needed to support the routine use of antioxidant vitamins.
Inoculation.
Influenza vaccination should be administered annually to patients with CABG unless contraindicated.