We recommend that in patients with ACS requiring CABG, the risk of bleeding vs the benefit of continuing dual antiplatelet therapy (DAPT) be weighed in deciding the appropriate timing of intervention (Strong, Low).

We suggest that, if possible, in patients scheduled for CABG, clopidogrel and ticagrelor be discontinued for 5 days and prasugrel for 7 days before surgery (Conditional, Low).

We recommend that DAPT be continued for 12 months in patients with ACS after CABG (Strong, Moderate).

Values and Preferences

• These recommendations recognize the advantage of antiplatelet therapy after CABG to prevent early graft occlusion and cardiovascular events, and the importance of weighing the benefits and risks of DAPT when deciding the timing of surgery.

Practical tips

• In stable patients with ACS without critical coronary anatomy who are clinically stable, clopidogrel and ticagrelor should be withheld for 5 days and prasugrel for 7 days before CABG.
• In patients with ACS, DAPT should be restarted at maintenance dose within 48-72 hours after surgery when deemed safe by the cardiac surgical team.

Antiplatelet Therapy Management of Patients after Coronary Artery Bypass Surgery (CABG)

• Low dose ASA is long considered the standard of care post CABG
• Studies of dual antiplatelet therapy (DAPT) following CABG have had conflicting results regarding graft related outcomes
• Regardless of its effect on graft-related outcomes, DAPT likely reduces overall thrombotic complications in patients with ACS who undergo CABG
• Large trials of DAPT with clopidogrel, prasugrel and ticagrelor have demonstrated similar outcome benefits in patients undergoing CABG
• Because of the greater potency of these newer antiplatelet therapies, cardiac surgeons must balance bleeding and efficacy in determining the timing of CABG after ACS. In stable patients with non-life-threatening coronary anatomy, therapy should ideally be withheld for 5 days for clopidogrel or ticagrelor and 7 days for prasugrel.
• In unstable and emergent patients, surgeons must weigh the potential risk of excess bleeding