Perioperative Management of Atrial Fibrillation

Pharmacological Interventions

• Digoxin and nondihydropyridine calcium channel blockers are useful for controlling ventricular rate in atrial fibrillation but are not indicated for prophylaxis, according to the American Heart Association 1
• Beta-blockers should be administered for at least 24 hours before CABG and reinstituted as soon as possible afterward, and prescribed to all CABG patients without contraindications at hospital discharge, as recommended by the American College of Cardiology/American Heart Association 1
• Statins should not be discontinued before or after CABG, and should be continued unless contraindicated, with a target LDL cholesterol <100 mg/dL and at least 30% reduction from baseline, as recommended by the American College of Cardiology/American Heart Association 1, 2
• Aspirin (100-325 mg daily) should be initiated within 6 hours postoperatively and continued indefinitely to prevent saphenous vein graft closure and reduce adverse cardiovascular events, as recommended by the American Heart Association, the European Society of Cardiology, and the American College of Cardiology 3, 4, 5, 2, 1
• ACE inhibitors/ARBs should be used, especially for patients with EF ≤40%, hypertension, diabetes, or CKD, as part of the post-CABG medication management plan, as recommended by the European Heart Society 6
• Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor should be considered for patients at increased risk of graft occlusion who are not at high bleeding risk, based on low-quality evidence, and for patients with recent acute coronary syndrome (ACS) or stent placement before CABG, a P2Y12 inhibitor should be added for 12 months, as recommended by the American College of Cardiology 7, 4
• The European Society of Cardiology recommends limiting triple therapy with aspirin, clopidogrel, and an oral anticoagulant to 1 month maximum, even in patients at high thrombotic risk, due to excessive bleeding risk, particularly in elderly patients 7

Infection Prevention and Management

• Preoperative antibiotics should be administered to all patients to reduce surgical site infections, with first- or second-generation cephalosporin recommended for patients without methicillin-resistant Staphylococcus aureus (MRSA) colonization, and vancomycin alone or in combination with other antibiotics recommended for patients with proven or suspected MRSA colonization, as suggested by the American College of Cardiology and the European Society of Cardiology 3, 1
• Evaluate sternal incision and graft harvest sites for signs of infection, proper healing progression, and need for aggressive surgical debridement in case of deep sternal wound infection, with deep sternal wound infections requiring aggressive surgical debridement and early muscle flap coverage 3, 1
• Aggressive control of perioperative hyperglycemia with continuous insulin infusion is recommended to prevent surgical site infections, according to the American College of Cardiology 3, 1, 2, 8

Cardiac Rehabilitation and Follow-up

• The American Heart Association recommends confirmation of enrollment and participation in cardiac rehabilitation program (Class I recommendation), with all patients referred to cardiac rehabilitation programs, which reduces cardiovascular mortality by 26% and overall mortality by 20% 2, 9, 7
• Cardiac rehabilitation programs should include baseline patient assessments, nutritional counseling (Mediterranean diet recommended), risk factor management (lipids, blood pressure, weight, diabetes, smoking), psychosocial interventions, and physical activity with counseling and exercise training, to promote lifestyle modification and risk reduction, as recommended by the European Society of Cardiology and the American Heart Association 9
• Regular follow-up visits are crucial to assess blood pressure control, lipid levels, glycemic control, medication adherence, and symptoms of recurrent ischemia, and to adjust management as needed, as recommended by the European Society of Cardiology and the American Heart Association 2

Patient Education and Support

• Patients should be provided with clear written and verbal instructions about medication type, purpose, dose, frequency, and side effects, as well as recognition of symptoms of worsening myocardial ischemia and when to seek emergency care, as recommended by the American Heart Association and the American College of Cardiology 10, 11
• A chest pain protocol should be established, where patients are instructed to call emergency services if chest pain is unimproved after one sublingual NTG, as recommended by the American Heart Association 10
• Electrocardiogram should be used to detect silent ischemia or arrhythmias, with coronary CT Angiography (CCTA) particularly useful for assessing graft patency, with 99% sensitivity and specificity for detecting complete graft occlusions, and should be considered for patients with chest pain or suspected graft failure, as recommended by the European Society of Cardiology and the American Heart Association 2, 12

Psychological Support and Lifestyle Modifications

• Up to 33% of patients may experience depression 1 year after CABG, which increases the risk of postoperative mortality, heart failure hospitalization, MI, cardiac arrest, and need for repeat revascularization, with depression screening crucial and managed with appropriate therapy and follow-up, as recommended by the European Society of Cardiology and the American Heart Association 9, 2, 1
• Consider referral for cognitive behavioral therapy or collaborative care if depression is detected, with failing to screen for depression associated with increased cardiac events and recurrence of angina 9
• Smoking cessation: All smokers should receive in-hospital educational counseling and be offered smoking cessation therapy, as recommended by the American Heart Association 1