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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 e72 CLINICAL STATEMENTS AND GUIDELINES general secondary prevention in patients with a distant history of CABG is not well established. Recommendation-Specific Supporting Text 1. Surgical bleeding remains a concern in the perioperative and immediate postoperative periods, and therefore bleeding risk is an important consideration in the use of antiplatelet therapy. Older data have shown that aspirin improves vein graft patency.1,2,5,6 Although 1 small study demonstrated higher rates of bleeding with aspirin after CABG,12 the totality of evidence supports the early use1-6 of aspirin to improve SVG patency and reduce ischemic complications. 2. Small RCTs, observational data, and meta-analyses have demonstrated that DAPT (mostly with aspirin and clopidogrel) after CABG improves vein graft patency, primarily among patients undergoing offpump surgery. The DACAB (Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Graft Surgery) trial10 compared DAPT with a single antiplatelet regimen in 500 patients undergoing CABG. Off-pump procedures were performed in 75% of these patients. At 1-year follow-up, the DAPT group was found to have the highest vein graft patency, when assessed with coronary computed tomography angiogram, compared with aspirin alone. 14.4 Beta Blockers in Patients After Revascularization Recommendation for Beta Blockers in Patients After Revascularization Referenced studies that support the recommendation are summarized in Online Data Supplement 46. COR LOE Recommendation 3: No benefit C-LD 1. In patients with SIHD and normal left ventricular function, the routine use of chronic oral beta blockers is not beneficial to reduce cardiovascular events after complete revascularization.1-6 Synopsis In patients who have undergone revascularization, the risks and benefits of beta blockers should be considered before the initiation of therapy. The benefit of beta blockers for secondary prevention after acute infarction or for those with left ventricular dysfunction has been clearly reported in clinical trials examining these subgroups, and recommendations based on this evidence are outlined in previous guidelines.7,8 However, in patients without acute infarction or left ventricular dysfunction, there is a paucity of data to support a benefit of the routine use of beta blockers after revascularization, especially in patients without residual disease. Further risk reduction may not be useful in patients after MI with normal left ventricular ejection fraction in the presence of GDMT with antiplatelet treatment, statins, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Thus, in the absence of new data to guide current therapy, clinicians will need to make decisions on an individualized basis. Recommendation-Specific Supportive Text 1. A large meta-analysis of patients undergoing PCI for stable angina showed no differences in adjusted rates of death, MI, stroke, or revascularization but a higher rate of heart failure readmissions among patients who were prescribed a beta blocker at hospital discharge.1 The REACH (Reduction of Atherothrombosis for Continued Health) Registry’s investigators showed that, after a median of 44 months’ follow-up, beta-blocker use was not associated with a reduction in the composite cardiovascular outcome in a large cohort of patients with SIHD.2 Additional studies have also supported an increased incidence of heart failure in patients treated with beta blockers in the reperfusion era.9 In a large cohort of patients with newly diagnosed CAD, a modest benefit of beta-blocker use was reported, although this benefit was noted only in patients with a previous MI.4 Hence, the decision to continue beta blockers in the long term in patients after revascularization should be made on an individualized basis. 14.5 Beta Blockers for the Prevention of Atrial Fibrillation After CABG Recommendation for Beta Blockers for the Prevention of Atrial Fibrillation After CABG Referenced studies that support the recommendation are summarized in Online Data Supplement 47. COR LOE Recommendation 1 B-R 1. In patients after CABG, beta blockers are recommended and should be started as soon as possible to reduce the incidence or clinical sequelae of postoperative atrial fibrillation.1-7 Synopsis New-onset postoperative atrial fibrillation occurs in about 18% of patients after CABG and is associated with a 4-fold increased risk of stroke and a 3-fold increase in all-cause mortality rate.8,9 Postoperative atrial fibrillation after CABG can be challenging to prevent and treat. Recommendation-Specific Supportive Text 1. RCTs have yielded conflicting results with regard to the ability of beta blockers to influence perioperative cardiovascular morbidity and mortality. A large meta-analysis found that beta-blocker use may reduce the incidence of atrial fibrillation and Downloaded from http://ahajournals.org by on October 7, 2026