Marc Ruel, MD, MPH, is a professor and the endowed chair and director of minimally invasive cardiac research in the division of cardiac surgery at the University of Ottawa Heart Institute.

Marc Ruel, MD, MPH

AHA Releases Updated Guidelines for Secondary Prevention Post-CABG

A new statement from the American Heart Association (AHA) has provided updated evidence and suggestions for coronary artery bypass grafting (CABG) and postoperative management in patients with 

The last guideline update published by the AHA on secondary prevention after CABG was in 2015. The document was constructed from 2 2011 AHA and American College of Cardiology Foundation (ACCF) documents, which summarized the use of medical therapy after coronary revascularization. The 2026 update follows over a decade of evidence collection and highlights significant progress in both pre- and postoperative disease management.

“Over the last 11 years, what we’ve seen is not only progress with regards to the type of surgery that we do, but how patients are cared for and the relative safety of the surgery,” Marc Ruel, MD, MPH, a professor and the endowed chair and director of minimally invasive cardiac research in the division of cardiac surgery at the University of Ottawa Heart Institute and co-author of the statement, told 

. “We know now that there are so many interacting factors that can make a patient derive a better outcome – not only with regards to preserving the patency of the grafts but also preventing more cardiometabolic disease or cerebral vascular disease or even coronary artery disease.”

The present document highlights several major areas of focus in postoperative CAD treatment, given that the disease continues to progress after CABG. Among these are lipid management, antithrombotic therapy, and antihypertensive therapy, as well as disease management for patients with diabetes.

 profiles, including high low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), or high triglyceride levels. Despite the use of high-intensity statins, many patients fail to attain lipid targets; additionally, LDL-C levels at 1 year following CABG are associated with long-term major adverse cardiovascular events (MACEs).

To address this, the document recommends an LDL-C threshold target of 55 mg/dL, with levels no higher than 70 mg/dL. Additionally, the authors suggest high-intensity or maximally tolerated statin therapy as a first-line therapy, with ezetimibe recommended for second-line and PCSK9 inhibitors or icosapent ethyl as third-line therapies.

Ruel and colleagues note that dual antiplatelet therapy (DAPT) and the addition of oral anticoagulants to antiplatelet therapy frequently increase bleeding risk following CABG. To this end, the document suggests initiating low-dose aspirin within 6 hours of CABG conclusion – this treatment effectively improves graft patency and reduces future cardiovascular events. However, higher doses can potentially increase gastrointestinal bleeding risk. Additionally, the authors suggest DAPT for 1 year following CABG in patients with acute coronary syndrome (ACS), given its association with a lower risk of death and cardiac events. While routine DAPT is not indicated in patients with chronic coronary disease, DAPT with aspirin and clopidogrel or ticagrelor can be considered to prevent graft failure in patients who are not at a high risk of bleeding.

The document implores clinicians to work for extremely strict blood pressure goals, given the activation of several neurohumoral and endogenous vasodilator systems early after CABG – in particular, Ruel and colleagues suggest a target of <130/<80 mmHg. Additionally, the document points out that ACE inhibitors and ARBs are indicated for patients with a clinical indication beyond CABG, including previous MI, diabetes, 

, reduced left ventricular ejection fraction, and 

. Calcium channel blockers are also recommended for the first postoperative year, along with dihydropyridines to help limit radial artery graft spasm.

Following CABG, the guidelines recommend that clinicians prioritize SGLT2 inhibitors for patients with diabetes regardless of baseline HbA1c, primarily for use in reducing MACEs and providing renal protection. Additionally, SGLT2 inhibitors should be utilized in patients with heart failure irrespective of diabetes status or ejection fraction. GLP-1 RAs are also flagged for prioritization in patients with diabetes or a body mass index (BMI) >27 kg/m2 to reduce MACEs.

Ultimately, these guidelines reflect 11 years of evidence collection in both CABG and follow-up therapy, bringing the field substantially further from the 2015 guidelines. However, Ruel and colleagues also acknowledge that further research must be conducted to optimize treatment for all patients both before and after the operation.

“Going forward, I think we can only go up from where we are,” Ruel said. “The 2015 statement helped achieve some strides in various jurisdictions. We’re not there yet, but we are making progress, and hopefully this statement helps.”

Editors’ Note: Ruel reports no relevant disclosures.

Ruel M, Sandner S, Ponnambalam M, et al. Secondary prevention after coronary artery bypass graft surgery: 2026 update: A scientific statement from the American Heart Association. Circulation. Published online May 13, 2026. 

Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery. Circulation. 2015;131(10):927-964. 

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Marc Ruel, MD, MPH, discusses the progress made since in the 11 years since the last guidelines, both in treatment and therapy.

Marc Ruel, MD, MPH

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