Impact of Preoperative and Postoperative Modern Guideline-Directed Medical Therapy on Survival After Coronary Artery Bypass Grafting.

Abstract

This study evaluated the association between preoperative or postoperative heart failure guideline-directed medication (GDMT) prescribing and midterm survival after coronary artery bypass grafting (CABG). The study included the records of 4307 adult patients who underwent outpatient, elective isolated CABG from January 2016 to December 2024 and who were discharged alive, and merged our institutional The Society of Thoracic Surgeons database with electronic health record medication data. GDMT class prescribing preoperatively (within 2 weeks of admission) and at discharge was identified: beta-blockers; angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and angiotensin receptor-neprilysin inhibitors; sodium-glucose cotransporter 2 inhibitors; and mineralocorticoid receptor antagonists. The primary outcome was mortality on follow-up. A total of 4307 patients who underwent elective, isolated CABG were included with mean age of 64 (SD 11) years and a mean Society of Thoracic Surgeons predicted risk of mortality score 1.3% (1.4%). Preoperatively, 5.2% (222 of 4307) of all patients and 13.3% (40 of 300) of patients with an ejection fraction ≤40% and a glomerular filtration rate >30 mL/min were admitted on 3+ GDMT medication classes. Postoperatively, 25.0% (1078 of 4307) of all patients and 56.3% (169 of 300) of patients with an ejection fraction ≤40% and a glomerular filtration rate >30 mL/min were discharged on 3+ classes. Over a median of 426 days of follow-up (interquartile range, 34-1190 days), 7.2% (309 of 4307) of patients died. One-year overall survival was 96.2%, and 3-year overall survival was 90.9%. Although no protective association was seen for preoperative GDMT, an increasing number of postoperative GDMT medications was independently associated with reduced follow-up mortality (all patients: hazard ratio [HR], 0.64; 95% CI, 0.55-0.74; P < .001), even after controlling for postoperative complications. The strongest independent associations were noted for postoperative sodium-glucose cotransporter 2 inhibitors (HR, 0.39; 95% CI, 0.27-0.56; P < .001) and the class comprising angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and angiotensin receptor-neprilysin inhibitors (HR, 0.61; 95% CI, 0.45-0.83; P = .001). The number of postoperative GDMT medication classes prescribed at discharge after CABG was strongly associated with reduced mortality.