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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e68 CLINICAL STATEMENTS AND GUIDELINES 13.2 Antiplatelet Therapy in Patients Undergoing CABG Recommendations for Antiplatelet Therapy in Patients Undergoing CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 42. 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.1-7 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.8-11 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.12-14 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.8,9,11,15-23 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.24,25 Synopsis The use of aspirin and antiplatelet agents in patients undergoing CABG is discussed with the Heart Team to determine the optimal treatment for each patient, with careful consideration of the risk of myocardial ischemia, significant bleeding, reoperation, and transfusion. The present recommendations are based on the severity of the patient’s condition and the associated surgical necessity. When the various therapies are considered, the urgency of the planned surgery should be determined, as outlined in Table 7 (Section 5.2).26,27 Recommendation-Specific Supporting Text 1. Most patients who undergo CABG are already taking aspirin for primary or secondary prevention of new cardiovascular events. Early observational data showed an association between preoperative aspirin administration and reduced in-hospital mortality rate.1,2 Although more recent meta-analyses of randomized and nonrandomized trials have yielded somewhat conflicting results, continuation of existing preoperative aspirin is likely associated with a reduction in the risk of MI but not death.3-5 Continuation of aspirin until the time of surgery is associated with an increased risk of perioperative bleeding and transfusion, although this does not appear to increase the likelihood of surgical reoperation.3-7 Patients at risk of significant bleeding (eg, redo operations or underlying bleeding dyscrasias) may warrant individualized consideration but are underrepresented in the literature. 2. The coadministration of aspirin and a P2Y12 receptor inhibitor (ie, clopidogrel, ticagrelor, prasugrel) is common, particularly in the setting of ACS or recent stent placement. In such patients, the risk of ischemic events must be weighed against the risks of bleeding when decisions are made about the cessation of P2Y12 receptor inhibitors before CABG.8-11 3. Glycoprotein IIb/IIIa inhibitors (ie, eptifibatide, tirofiban, abciximab) are sometimes given to patients who are at high risk of acute ischemic events while they are awaiting CABG. The therapeutic half-life for each glycoprotein IIb/IIIa inhibitor, in addition to a patient’s renal function, are considered in the determination of safe discontinuation before CABG, and data from observational studies have established optimal cessation periods before CABG for each agent with reasonable safety profiles.12-14 Abciximab may not be readily available to clinicians in the United States. 4. CABG performed <5 days after the discontinuation of clopidogrel is associated with an increased risk of major bleeding complications, such as tamponade or reoperation, a finding that was suggested by early observational data.9,15 and confirmed by more recent randomized and nonrandomized trials.10,16-18 Early experience also suggested that preoperative ticagrelor should be withheld for a similar time frame (5 days) before surgery to reduce bleeding and blood product administration.11,19 However, platelet inhibition assay results from 1 randomized study20 and more recent data from 2 separate observational trials have revealed that delaying surgery for 72 hours is likely sufficient.8,21 The timing for prasugrel is less established but results from the TRITON-TIMI-38 trial suggested that among patients who underwent CABG, prasugrel resulted in a higher rate of major bleeding than that seen with clopidogrel.22 In a subset of patients in the ACCOAST (A Comparison of Prasugrel at PCI or Time of Diagnosis of Non–ST-Elevation Myocardial Infarction) study, early surgery (<3 days after discontinuation of prasugrel) led to an increased risk of bleeding and ischemic complications, whereas later surgery (>7 days) did not.23 5. Initiation of aspirin therapy in the immediate preoperative period (<24 hours) has been investigated in 2 randomized trials. In the first trial,24 patients undergoing CABG who received 100 mg of aspirin Downloaded from http://ahajournals.org by on October 7, 2026