Pharmacotherapy in patients undergoing CABG: Difference between revisions

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=== Primary Prevention Adults 40 to 75 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.7 to 4.8 mmol/L) ===
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Pharmacotherapy in patients undergoing CABG ==
 
=== Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG ===
{| class="wikitable" style="width:80%"
{| class="wikitable" style="width:80%"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In adults at intermediate-risk, statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients undergoing CABG, an intraoperative continuous insulin infusion should be initiated to maintain serum glucose level <180 mg/dL to reduce sternal wound infection''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In intermediate-risk patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in high-risk patients, levels should be reduced by 50% or more. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients undergoing CABG, the use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration of <180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' For the primary prevention of clinical ASCVD* in adults 40 to 75 years of age without diabetes mellitus and with an LDL-C level of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), the 10-year ASCVD risk of a first “hard” ASCVD event (fatal and nonfatal MI or stroke) should be estimated by using the race- and sex-specific PCE, and adults should be categorized as being at low risk (<5%), borderline risk (5% to <7.5%), intermediate-risk (≥7.5% to <20%), and high-risk (≥20%)''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients undergoing CABG, a comprehensive approach to reducing sternal wound infections is recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35286170">{{cite journal| author=| title=Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 11 | pages= e771 | pmid=35286170 | doi=10.1161/CIR.0000000000001061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286170  }}</ref>
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 4. In patients undergoing CABG, the usefulness of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration <140 mg/dL is uncertain (Level of Evidence B-R)".
|}
 
=== <ref name="pmid35286170" /> Antiplatelet Therapy in Patients Undergoing CABG ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients undergoing CABG who are already taking daily aspirin preoperatively, it is recommended that they continue taking aspirin until the time of surgery to reduce ischemic events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours before surgery to reduce major bleeding complication''[[ACC AHA guidelines classification scheme#Level of Evidence|(Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In patients undergoing CABG, discontinuation of short-acting glycoprotein IIb/IIIa inhibitors (eptifibatide and tirofiban) for 4 hours and abciximab for 12 hours before surgery is recommended to reduce the risk of bleeding and transfusion''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])'' <nowiki>"</nowiki>
|}
 
=== <ref name="pmid35286170" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 4. In patients undergoing elective CABG who receive P2Y12 receptor inhibitors before surgery, it is reasonable to discontinue clopidogrel for 5 days, ticagrelor for 3 days, and prasugrel for 7 days before CABG to reduce the risk of major bleeding and blood product transfusion. (Level of Evidence B-R)".
|}
 
=== <ref name="pmid35286170" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
| bgcolor="LightCoral" |"5. In patients undergoing elective CABG who are not already taking aspirin, the initiation of aspirin (100–300 mg daily) in the immediate preoperative period (<24 hours before surgery) is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
|}
 
=== <ref name="pmid35286170" /> ===
 
=== Beta Blockers and Amiodarone in Patients Undergoing CABG ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 1'''.''' In patients undergoing CABG, who do not have a contraindication to beta blockers, the administration of beta blockers before surgery can be beneficial to reduce the incidence of postoperative atrial fibrillation (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 2. In patients undergoing CABG, preoperative amiodarone is reasonable to reduce the incidence of postoperative atrial fibrillation. (Level of Evidence B-R)<nowiki>''</nowiki>
|}
 
=== <ref name="pmid35286170" /> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 3'''.''' In patients undergoing CABG, who do not have a contraindication to beta blockers, preoperative use of beta blockers may be effective in reducing in-hospital and 30-day mortality rates (Level of Evidence B-NR)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 4. In patients undergoing CABG, the role of preop-erative beta blockers for the prevention of acute postoperative myocardial ischemia, stroke, AKI, or ventricular arrhythmia is uncertain.(Level of Evidence B-NR)<nowiki>''</nowiki>
|}
 
=== <ref name="pmid35286170" /> ===
 
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Pharmacotherapy in patients after CABG ==
 
=== Antiplatelet Therapy in Patients After CABG ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients undergoing CABG, aspirin (100–325 mg daily) should be initiated within 6 hours postoperatively and then continued indefinitely to reduce the occurrence of SVG closure and adverse cardiovascular events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LemonChiffon" |" 2'''.''' In selected patients undergoing CABG, DAPT with aspirin and ticagrelor or clopidogrel for 1 year may be reasonable to improve vein graft patency compared with aspirin alone(Level of Evidence B-R)".
|}
<ref name="pmid35286170" />
 
=== Beta Blockers for the Prevention of Atrial Fibrillation After CABG ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients after CABG, beta blockers are recommended and should be started as soon as possible to reduce the incidence or clinical sequelae of postoperative atrial fibrillation''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R)]]'' <nowiki>"</nowiki>
|}
<ref name="pmid35286170" />
 
== References ==

Latest revision as of 13:16, 6 December 2022

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Pharmacotherapy in patients undergoing CABG

Insulin Infusion and Other Measures to Reduce Sternal Wound Infection in Patients Undergoing CABG

Class I
"1. In patients undergoing CABG, an intraoperative continuous insulin infusion should be initiated to maintain serum glucose level <180 mg/dL to reduce sternal wound infection(Level of Evidence: B-R) "
"2. In patients undergoing CABG, the use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration of <180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection. (Level of Evidence: B-R) "
"3. In patients undergoing CABG, a comprehensive approach to reducing sternal wound infections is recommended(Level of Evidence: B-NR) "

[1]

Class IIb
" 4. In patients undergoing CABG, the usefulness of continuous intravenous insulin designed to achieve a target intraoperative blood glucose concentration <140 mg/dL is uncertain (Level of Evidence B-R)".

[1] Antiplatelet Therapy in Patients Undergoing CABG

Class I
"1. In patients undergoing CABG who are already taking daily aspirin preoperatively, it is recommended that they continue taking aspirin until the time of surgery to reduce ischemic events.(Level of Evidence: B-R) "
"2. In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours before surgery to reduce major bleeding complication(Level of Evidence: B-NR) "
"3. In patients undergoing CABG, discontinuation of short-acting glycoprotein IIb/IIIa inhibitors (eptifibatide and tirofiban) for 4 hours and abciximab for 12 hours before surgery is recommended to reduce the risk of bleeding and transfusion(Level of Evidence: B-NR) "

[1]

Class IIa
" 4. In patients undergoing elective CABG who receive P2Y12 receptor inhibitors before surgery, it is reasonable to discontinue clopidogrel for 5 days, ticagrelor for 3 days, and prasugrel for 7 days before CABG to reduce the risk of major bleeding and blood product transfusion. (Level of Evidence B-R)".

[1]

Class III (No Benefit)
"5. In patients undergoing elective CABG who are not already taking aspirin, the initiation of aspirin (100–300 mg daily) in the immediate preoperative period (<24 hours before surgery) is not recommended. (Level of Evidence:B-R) "

[1]

Beta Blockers and Amiodarone in Patients Undergoing CABG

Class IIa
" 1. In patients undergoing CABG, who do not have a contraindication to beta blockers, the administration of beta blockers before surgery can be beneficial to reduce the incidence of postoperative atrial fibrillation (Level of Evidence B-R)".
'' 2. In patients undergoing CABG, preoperative amiodarone is reasonable to reduce the incidence of postoperative atrial fibrillation. (Level of Evidence B-R)''

[1]

Class IIb
" 3. In patients undergoing CABG, who do not have a contraindication to beta blockers, preoperative use of beta blockers may be effective in reducing in-hospital and 30-day mortality rates (Level of Evidence B-NR)".
'' 4. In patients undergoing CABG, the role of preop-erative beta blockers for the prevention of acute postoperative myocardial ischemia, stroke, AKI, or ventricular arrhythmia is uncertain.(Level of Evidence B-NR)''

[1]

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (Please do not edit). Pharmacotherapy in patients after CABG

Antiplatelet Therapy in Patients After CABG

Class I
"1. In patients undergoing CABG, aspirin (100–325 mg daily) should be initiated within 6 hours postoperatively and then continued indefinitely to reduce the occurrence of SVG closure and adverse cardiovascular events.(Level of Evidence: A) "

[1]

Class IIb
" 2. In selected patients undergoing CABG, DAPT with aspirin and ticagrelor or clopidogrel for 1 year may be reasonable to improve vein graft patency compared with aspirin alone(Level of Evidence B-R)".

[1]

Beta Blockers for the Prevention of Atrial Fibrillation After CABG

Class I
"1. In patients after CABG, beta blockers are recommended and should be started as soon as possible to reduce the incidence or clinical sequelae of postoperative atrial fibrillation(Level of Evidence: B-R) "

[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 "Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (11): e771. 2022. doi:10.1161/CIR.0000000000001061. PMID 35286170 Check |pmid= value (help).
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