40
Treatment
Antiplatelet Therapy in Patients Undergoing CABG
COR LOE
Recommendations
1 B-R 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.
1 B-NR 2. In patients referred for urgent CABG, clopidogrel and
ticagrelor should be discontinued for at least 24 hours before
surgery to reduce major bleeding complications.
1 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.
2a B-NR 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 risk of major
bleeding and blood product transfusion.
3: No
benefit
B-R 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.
Table 11. Best Practices to Reduce Sternal Wound Infection
in Patients Undergoing CABG
• Perform nasal swab testing for Staphylococcus aureus.
• Apply mupirocin 2% ointment to known nasal carriers of S. aureus.
• Apply preoperative intranasal mupirocin 2% ointment to those patients whose nasal
culture or polymerase chain reaction result is unknown.
• Redose prophylactic antimicrobials for long procedures (>2 half-lives of the
antibiotic) or in cases of excessive blood loss during CABG.
• Measure perioperative HbA
1c
.
• Treat all distant extrathoracic infections before nonemergency surgical coronary
revascularization.
• Advise smoking cessation before elective CABG surgery.
• Apply topical antibiotics (vancomycin) to the cut edges of the sternum on opening
and before closing in cardiac surgical procedures involving a median sternotomy.
• Use skeletonized harvest of IMA in BIMA grafting.
• Do not continue prophylactic antibiotics beyond 48 hours.
