This handout is for nstemi peri-operative — within 30 days post-cabg (udmi type 5 nstemi variant). Your care team identified this based on: troponin rise meeting udmi type 5 nstemi threshold (>10× url ctnt / >35× url ctni within 48 h of cabg, or sustained rise after expected post-pump fall) without st elevation.
Other reasons your team may use this plan: post-cabg troponin re-rise (after the expected initial post-pump fall toward baseline by 24-72 h) — graft thrombosis or distal embolization suspect; recurrent ischemic chest pain (or angina-equivalent: dyspnea, diaphoresis, hypotension) within 30 days post-cabg without ste; new regional wall-motion abnormality on post-cabg echo (vs pre-op or immediate post-op baseline) without ste — territorial graft failure suspect.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| aspirin | continue 81 mg daily (load 162-325 mg only if not previously on ASA) | PO | daily indefinitely | AHA 2025 ACS Class I + ACC/AHA 2021 Coronary Revasc (PMID 34882435) — lifelong post-CABG ASA; rarely needs new load since most post-CABG patients on chronic ASA |
| clopidogrel | 75 mg daily (continue if already on; load 300 mg only with CT-surg clearance if escalating from ASA-mono) | PO | daily × 12 mo per POPULAR-CABG PMID 34016267 | POPULAR-CABG PMID 34016267 — clopidogrel preferred P2Y12 in post-CABG window given bleed profile; CT-surg clearance mandatory before reload in first 7 d |
| ticagrelor | 180 mg load → 90 mg BID (ONLY after CT-surg clearance + chest tubes <100 mL/h × 4 h + day ≥7 post-op) | PO | BID × 12 mo if escalation indicated | PLATO PMID 19717846 — net benefit in ACS but bleed risk amplified peri-op; reserved for confirmed graft thrombosis + CT-surg clearance |
| unfractionated_heparin | 60 U/kg IV bolus + 12 U/kg/h infusion (HOLD if active chest tube bleed >100 mL/h or sternal dehiscence; CT-surg clearance mandatory) | IV | bolus + infusion at PCI; aPTT 50-70 or anti-Xa 0.3-0.7 | AHA 2025 Class I peri-PCI AC; UFH preferred over LMWH/fondaparinux in post-CABG window for reversibility (protamine) given bleed risk |
| atorvastatin | 80 mg daily | PO | daily lifelong | PROVE-IT PMID 15007110 — high-intensity statin lifelong; intensified post-CABG given graft attrition + advanced CAD substrate |
| metoprolol_tartrate | 12.5-25 mg BID titrate (HOLD if SBP <100, HR <60, EF <30 + acute decompensation) | PO | BID | CAPRICORN + ACC/AHA 2025 Class I post-MI BB; rate control for POAF (incidence 30-40% post-CABG) |
| norepinephrine | 0.05-0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II first-line vasopressor; vasoplegia common post-pump; restoring perfusion corrects type-2 demand component |
| amiodarone | 150 mg IV load over 10 min → 1 mg/min × 6 h → 0.5 mg/min | IV | load + infusion | AHA 2024 AF rate/rhythm control; POAF + demand ischemia + EF reduced; first-line for sustained VT post-op |
| sacubitril-valsartan | 24/26 mg BID titrate (start at ≥36 h post-ACEi, SBP ≥100) | PO | BID | PIONEER-HF PMID 30403955 + ACC/AHA 2022 HF Class I — initiate ARNI if HFrEF persists post-MI in stable post-op patient |
| eptifibatide | 180 µg/kg IV bolus + 2 µg/kg/min infusion (renal-adjust if eGFR <50) | IV | bolus + infusion at PCI for SVG no-reflow / large thrombus burden | EARLY ACS / TARGET — bailout GPIIb/IIIa for SVG-PCI no-reflow despite embolic protection; bleed risk amplified peri-op so reserved for true bailout |
| warfarin | 5 mg daily; INR 2-3 × 3 mo if LV thrombus on echo | PO | daily | AHA 2022 Class IIa — 3-mo AC for LV thrombus; AUGUSTUS framework if AF + ACS overlap (DAPT triple-therapy short window) |
Plan: Post-CABG peri-operative NSTEMI phenotype — driver-stratified regimen with CT-surgery-coordinated anti-thrombotic escalation; specialises parent cardio.nstemi.core.v1 for the 30-day post-CABG window
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiology + CT-surgery joint follow-up at 1, 4, 12 wks; heart pumping strength (LVEF) re-echo at 40-90 d for ICD eligibility (MADIT-II EF ≤30); cardiac rehab Class I per ACC/AHA 2025; intensified secondary prevention (high-intensity statin lifelong, BP <130/80, no smoking, the four foundational heart-failure medications if EF reduced); DAPT-duration plan per POPULAR-CABG (PMID 34016267)
Guideline: 4th Universal Definition of MI 2018 (Thygesen Circulation 2018, PMID 30153967) Type-5 criteria; 2025 ACC/AHA ACS Guideline (Rao); ACC/AHA 2021 Coronary Revascularization Guideline (Lawton, PMID 34882435); ESC 2023 NSTE-ACS (Byrne, PMID 37622670)