Practical Considerations for Secondary Prevention After CABG

Antithrombotic Therapy

• Initiate low-dose aspirin within 6 hours after CABG and continue indefinitely to improve graft patency and reduce cardiovascular events.
• Consider dual antiplatelet therapy (DAPT) for 1 year in patients with acute coronary syndrome (ACS) undergoing CABG to reduce the risk of death and cardiac events.
• Do not routinely use DAPT in chronic coronary disease after CABG. Consider aspirin with clopidogrel or ticagrelor for 1 year in patients without high bleeding risk to reduce graft failure risk.

Lipid Management

• Target LDL-C ≤55 mg/dL as the preferred goal and maintain LDL-C <70 mg/dL as an established threshold. Consider alternative targets of non-high-density lipoprotein cholesterol <85 mg/dL or apolipoprotein B ≤0.65 g/L.
• Use high-intensity or maximally tolerated statin therapy as first-line treatment.
• Add ezetimibe if statin therapy alone does not achieve LDL-C targets.
• Consider a PCSK9 inhibitor if statin plus ezetimibe therapy remains insufficient to achieve lipid goals. Consider icosapent ethyl in patients with triglyceride levels between 135 and 500 mg/dL.

β-Blocker Therapy

• Do not routinely initiate β-blockers within 24 hours before elective CABG in β-blocker-naive patients.
• Continue perioperative β-blockers in patients already receiving therapy to reduce postoperative atrial fibrillation (AF), particularly in high-risk patients.
• Consider long-term cardioselective β-blockers after CABG to reduce the risk of major adverse cardiovascular events (MACE), although consistent mortality reduction has not been demonstrated.

Antihypertensive Therapy

• Use angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients with standard indications, including previous myocardial infarction (MI), diabetes, heart failure, reduced left ventricular ejection fraction (LVEF), or hypertension.
• Consider calcium channel blockers during the first postoperative year to reduce radial artery graft spasm, with dihydropyridines preferred over nondihydropyridines.

Previous MI and Left Ventricular Dysfunction

• Use angiotensin receptor-neprilysin inhibitors (ARNis) as first-line therapy in patients with previous myocardial infarction (MI) and persistent left ventricular ejection fraction (LVEF) <40%, when feasible. Use angiotensin-converting enzyme (ACE) inhibitors if ARNi therapy is not feasible, or angiotensin receptor blockers (ARBs) if ACE inhibitors are not tolerated, in combination with β-blockers.
• In patients with persistent New York Heart Association (NYHA) class II to IV heart failure, LVEF <35%, and estimated glomerular filtration rate ≥30 mL/min/1.73 m², add a mineralocorticoid receptor antagonist (MRA). Sodium-glucose cotransporter 2 (SGLT2) inhibitors provide benefit in patients with symptomatic LVEF ≤40%.
• When clinically feasible, initiate all 4 foundational heart failure therapies, including ARNi or ACE inhibitor, β-blocker, MRA, and SGLT2 inhibitor, with support from coordinated follow-up, telemedicine, cardiac rehabilitation (CR), and primary care transitions.
• Evaluate eligible patients for implantable cardioverter defibrillator therapy for primary prevention of sudden cardiac death after MI or revascularization according to LVEF, NYHA class, guideline-directed medical therapy (GDMT), and arrhythmia risk. Early implantation after CABG may be considered in selected patients.

Diabetes Management

Long-Term Secondary Prevention 

• Prioritize sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with diabetes and a history of CABG regardless of baseline glycated hemoglobin (HbA1c), primarily to reduce the risk of major adverse cardiovascular events (MACE) and provide renal protection.
• Prioritize SGLT2 inhibitors in patients with heart failure after CABG regardless of diabetes status or ejection fraction, primarily to reduce cardiovascular death, hospitalization for heart failure, and cardiorenal events.
• Prioritize glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in post-CABG patients with diabetes or body mass index (BMI) >27 kg/m² without diabetes to reduce the risk of MACE regardless of baseline HbA1c.
• Prioritize GLP-1 RAs, particularly semaglutide, in patients with diabetes and concomitant peripheral artery disease to improve functional outcomes and reduce disease progression risk.

Perioperative Considerations

• Avoid SGLT2 inhibitors in patients with type 1 diabetes.
• When clinically appropriate, withhold SGLT2 inhibitors 3 days before CABG and restart once postoperative oral intake, including carbohydrate intake, resumes to reduce diabetic ketoacidosis risk.
• When clinically appropriate, stop once-weekly GLP-1 RAs 1 week before surgery and oral GLP-1 RAs 3 days before surgery. Resume therapy once adequate oral intake and bowel motility recover.

Smoking Cessation After CABG

• Smoking contributes to graft failure and increased risk of MACE after CABG. Smoking abstinence after CABG may reduce 5-year mortality risk by 35% and MACE risk by 18%.
• Document smoking status before CABG, provide smoking cessation counseling, and initiate structured smoking cessation support preoperatively. Smoking cessation at least 4 weeks before CABG may improve perioperative outcomes to levels comparable with those of never smokers.
• Continue longitudinal smoking cessation management through primary care or tobacco treatment programs.

Cardiac Rehabilitation and Exercise 

• Refer eligible patients with chronic CAD to cardiac rehabilitation (CR) within 4 weeks after discharge following MI, percutaneous coronary intervention, or CABG to improve clinical outcomes.
• Optimize CR by initiating prehabilitation before CABG when feasible, continuing rehabilitation during hospitalization, and extending care into the outpatient setting.
• Consider telerehabilitation as a flexible and accessible approach to CR delivery, particularly for older adults and patients unable to attend center-based programs.

Additional Cardiovascular Risk Reduction 

• Use structured behavioral weight-management strategies that incorporate dietary modification, exercise, self-efficacy, goal setting, stimulus control, and stress management when obesity is present.
• Consider strategies that achieve a net negative energy balance through exercise programs designed to maximize caloric expenditure and dietary counseling aimed at reducing energy intake.
• Consider pharmacologic weight-loss therapy in appropriate patients to support meaningful weight reduction and reduce the risk of MACE in patients with and without diabetes.
• Consider influenza and pneumococcal vaccination in individuals with atherosclerotic cardiovascular disease (ASCVD).
• Discuss adult vaccination strategies according to individual cardiovascular risk profiles.

Mental Health Management 

• Recognize that depression and anxiety commonly occur before and after CABG and correlate with increased risk of delirium and postoperative complications. Assess psychosocial risk factors and mood disturbances using clinical interviews or standardized assessment tools before and after surgery.
• Consider pharmacotherapy or psychotherapy for depression and anxiety according to established standards. Consider gastroprotective therapy when initiating selective serotonin reuptake inhibitors in patients with CAD receiving antiplatelet therapy.
• Use cardiac prehabilitation and CR programs to support physical recovery and improve symptoms of depression, anxiety, and hostility.
• Screen for preexisting conditions and frailty to guide individualized rehabilitation strategies and improve adherence to secondary prevention after CABG.