Secondary therapies play a key role in maintaining long-term graft patency, preventing adverse cardiovascular outcomes, and helping improve overall health and quality of life after CABG surgery. Recently, the American Heart Association (AHA) released a scientific statement on secondary prevention after CABG surgery. The statement was published in Circulation and is available for free online at http://circ.ahajournals.org.
The statement expands on two 2011 documents from the AHA and American College of Cardiology that only briefly reviewed secondary prevention for CABG recipients. “Since these documents were released, important evidence from clinical and observational trials has emerged to further support and broaden the use of intensive risk-reduction therapies for CABG recipients,” says Alexander Kulik, MD, MPH, who chaired the AHA writing panel that developed the consensus statement.
According to the scientific statement, postoperative antiplatelet agents and lipid-lowering therapy continue to be mainstays of secondary prevention after CABG. “The statement also supports using other strategies for improving long-term clinical outcomes after CABG,” says Dr. Kulik. “This includes aggressively managing hypertension and diabetes and promoting smoking cessation and weight loss. In addition, cardiac rehabilitation (CR)—although largely underused—is recommended for all patients after CABG. Patients should be referred to CR early after surgery during their initial hospital stay.”
The AHA also provides specific recommendations for the appropriate use of various cardiovascular therapies in CABG patients. The statement helps guide physicians on the most appropriate use of ACE inhibitors, angiotension receptor blockers, β-blockers, statins, and other important cardiovascular medications depending on each patient’s unique characteristics. Furthermore, the statement offers guidance on managing obesity and metabolic syndrome.
Other Key Points
According to the AHA scientific statement, it is reasonable to screen for depression for CABG patients in the perioperative period, in collaboration with primary care physicians and mental health specialists. Cognitive behavior therapy or collaborative care for those with clinical depression after CABG may be beneficial to reduce depression. Vitamin supplements, such as omega-3 fatty acids and antioxidants, can also be considered in CABG patients with specific vitamin deficiencies, but the effectiveness of these therapies is not well established. In addition, annual influenza vaccinations should be offered to all CABG patients, unless contraindicated.
Seizing the Opportunity
Dr. Kulik says comprehensive risk factor management after CABG can yield significant benefits to patients. “Secondary prevention is often a missed opportunity when caring for patients after CABG,” he says. “We need to change that by being more proactive and vigilant about using secondary therapies and by implementing these recommendations in appropriate patients.” He notes that healthcare systems can also help support these efforts by following these guidelines so that patients can achieve the maximum benefit after surgery.
Kulik A, Ruel M, Injeid H, et al, on the behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131:927-964. Available at: http://circ.ahajournals.org/content/131/10/927.full.
Smith SC Jr, Benjamin EJ, Bonow RO, et al; World Heart Federation and the Preventive Cardiovascular Nurses Association. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124:2458–2473.
Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:e652–e735.