Interpretation of the 2026 AHA Scientific Statement on Secondary Prevention After Coronary Artery Bypass Graft Surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHU Yunpeng ¹ , YUAN Xin ² , ZHU Jiaxi ¹ ,  FENG Wei ² ,  ZHAO Qiang ¹

1. Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P. R. China;
2. National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, 100037, P. R. China;

Corresponding?author：

FENG Wei, Email: fengwei@fuwai.com; ZHAO Qiang, Email: zq11607@rjh.com.cn

Keywords：

Coronary artery bypass grafting; coronary artery diseases; American Heart Association; scientific statement; patient-centered; secondary prevention; multidisciplinary management; guideline interpretation

DOI：

10.7507/1007-4848.202606052

Video：

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In May 2026, the American Heart Association (AHA) formally released the scientific statement "Secondary Prevention After Coronary Artery Bypass Graft Surgery: 2026 Update", which updates the 2015 statement. The new statement emphasizes a patient-centered shared decision-making model and further clarifies the application status of several novel drugs, including proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), sodium-glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1a), and angiotensin receptor-neprilysin inhibitors (ARNIs), in coronary artery bypass grafting (CABG) patients with relevant indications. This article systematically summarizes and interprets the major recommendations of the statement. In conjunction with the current status of postoperative management after CABG in China, it discusses the potential applicability, implementation barriers, and future research directions of these recommendations, with the aim of providing practical guidance for cardiac surgeons and other clinicians involved in the long-term management of patients after CABG.

1.	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, 2026, 153(25): e1408-e1426.
2.	Pinho-Gomes AC, Azevedo L, Ahn JM, et al. Compliance with guideline-directed medical therapy in contemporary coronary revascularization trials. J Am Coll Cardiol, 2018, 71(6): 591-602.
3.	Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation, 2015, 131(10): 927-964.
4.	Mangano DT. Aspirin and mortality from coronary bypass surgery. N Engl J Med, 2002, 347(17): 1309-1317.
5.	Jones WS, Mulder H, Wruck LM, et al. Comparative effectiveness of aspirin dosing in cardiovascular disease. N Engl J Med, 2021, 384(21): 1981-1990.
6.	Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(3): e4-e17.
7.	Myles PS, Smith JA, Forbes A, et al. Stopping vs. continuing aspirin before coronary artery surgery. N Engl J Med, 2016, 374(8): 728-737.
8.	Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation, 2004, 110(10): 1202-1208.
9.	Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol, 2011, 57(6): 672-684.
10.	Jeppsson A, James S, Moller CH, et al. Ticagrelor and aspirin or aspirin alone after coronary surgery for acute coronary syndrome. N Engl J Med, 2025, 393(23): 2313-2323.
11.	Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA, 2018, 319(16): 1677-1686.
12.	Sandner S, Redfors B, Angiolillo DJ, et al. Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery: a systematic review and meta-analysis. JAMA, 2022, 328(6): 554-562.
13.	Solo K, Lavi S, Kabali C, et al. Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis. BMJ, 2019, 367: l5476.
14.	Zhu Y, Zhang W, Dimagli A, et al. Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial. BMJ, 2024, 385: e075707.
15.	Yuan X, Li J, Lei L, et al. Efficacy of dual antiplatelet therapy for three months versus 12 months after coronary artery bypass grafting: multicentre, double blinded, randomised controlled trial. BMJ, 2026, 393: e088939.
16.	Lamy A, Eikelboom J, Sheth T, et al. Rivaroxaban, aspirin, or both to prevent early coronary bypass graft occlusion: the COMPASS-CABG study. J Am Coll Cardiol, 2019, 73(2): 121-130.
17.	Gaudino M, Di Franco A, Rong LQ, et al. Postoperative atrial fibrillation: from mechanisms to treatment. Eur Heart J, 2023, 44(12): 1020-1039.
18.	van de Kar MRD, van Brakel TJ, Van't Veer M, et al. Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis. Eur Heart J, 2024, 45(29): 2620-2630.
19.	Kulik A, Brookhart MA, Levin R, et al. Impact of statin use on outcomes after coronary artery bypass graft surgery. Circulation, 2008, 118(18): 1785-1792.
20.	Campeau L, Enjalbert M, Lespérance J, et al. The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation. A study 10 years after aortocoronary bypass surgery. N Engl J Med, 1984, 311(21): 1329-1332.
21.	Domanski MJ, Borkowf CB, Campeau L, et al. Prognostic factors for atherosclerosis progression in saphenous vein grafts: the postcoronary artery bypass graft (Post-CABG) trial. J Am Coll Cardiol, 2000, 36(6): 1877-1883.
22.	Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J, 2020, 41(1): 111-188.
23.	Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J, 2021, 42(34): 3227-3337.
24.	Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2023, 148(9): e9-e119.
25.	Eisen A, Cannon CP, Blazing MA, et al. The benefit of adding ezetimibe to statin therapy in patients with prior coronary artery bypass graft surgery and acute coronary syndrome in the IMPROVE-IT trial. Eur Heart J, 2016, 37(48): 3576-3584.
26.	Goodman SG, Aylward PE, Szarek M, et al. Effects of alirocumab on cardiovascular events after coronary bypass surgery. J Am Coll Cardiol, 2019, 74(9): 1177-1186.
27.	Ferguson TB, Coombs LP, Peterson ED, et al. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA, 2002, 287(17): 2221-2227.
28.	Zhang H, Yuan X, Zhang H, et al. Efficacy of long-term β-blocker therapy for secondary prevention of long-term outcomes after coronary artery bypass grafting surgery. Circulation, 2015, 131(25): 2194-2201.
29.	Bj?rklund E, Nielsen SJ, Hansson EC, et al. Secondary prevention medications after coronary artery bypass grafting and long-term survival: a population-based longitudinal study from the SWEDEHEART registry. Eur Heart J, 2020, 41(17): 1653-1661.
30.	Rouleau JL, Warnica WJ, Baillot R, et al. Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery. Circulation, 2008, 117(1): 24-31.
31.	Ruel M, Sun LY. Post-operative calcium-channel blocker use after radial artery grafting: do we now have a definitive answer? J Am Coll Cardiol, 2019, 73(18): 2307-2309.
32.	Gaudino M, Benedetto U, Fremes SE, et al. Effect of calcium-channel blocker therapy on radial artery grafts after coronary bypass surgery. J Am Coll Cardiol, 2019, 73(18): 2299-2306.
33.	Zhu Y, Zhang W, Qin K, et al. Effects of nicorandil, isosorbide mononitrate, or diltiazem on radial artery grafts after CABG: the randomized ASRAB-Pilot trial. Circ Cardiovasc Interv, 2025, 18(4): e014542.
34.	Maddox TM, Januzzi JL, Allen LA, et al. 2024 ACC expert consensus decision pathway for treatment of heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol, 2024, 83(15): 1444-1488.
35.	Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(18): e895-e1032.
36.	McDonagh TA, Metra M, Adamo M, et al. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J, 2023, 44(37): 3627-3639.
37.	Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 2018, 138(13): e272-e391.
38.	Kusumoto FM, Calkins H, Boehmer J, et al. HRS/ACC/AHA expert consensus statement on the use of implantable cardioverter-defibrillator therapy in patients who are not included or not well represented in clinical trials. Circulation, 2014, 130(1): 94-125.
39.	Joseph JJ, Deedwania P, Acharya T, et al. Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: a scientific statement from the American Heart Association. Circulation, 2022, 145(9): e722-e759.
40.	Verma S, Emerson S, Plutzky J, et al. Semaglutide improves cardiovascular outcomes in patients with history of coronary artery bypass graft and obesity. J Am Coll Cardiol, 2025, 85(5): 541-545.
41.	Marx N, Husain M, Lehrke M, et al. GLP-1 receptor agonists for the reduction of atherosclerotic cardiovascular risk in patients with type 2 diabetes. Circulation, 2022, 146(24): 1882-1894.
42.	Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med, 2023, 389(24): 2221-2232.
43.	Castagna MT, Mintz GS, Ohlmann P, et al. Incidence, location, magnitude, and clinical correlates of saphenous vein graft calcification: an intravascular ultrasound and angiographic study. Circulation, 2005, 111(9): 1148-1152.
44.	Gaudino M, Sandner S, An KR, et al. Graft failure after coronary artery bypass grafting and its association with patient characteristics and clinical events: a pooled individual patient data analysis of clinical trials with imaging follow-up. Circulation, 2023, 148(17): 1305-1315.
45.	Scheenstra B, van Susante L, Bongers BC, et al. The effect of teleprehabilitation on adverse events after elective cardiac surgery: a randomized controlled trial. J Am Coll Cardiol, 2025, 85(8): 788-800.
46.	Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation, 1999, 99(16): 2192-2217.

1. 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, 2026, 153(25): e1408-e1426.
2. Pinho-Gomes AC, Azevedo L, Ahn JM, et al. Compliance with guideline-directed medical therapy in contemporary coronary revascularization trials. J Am Coll Cardiol, 2018, 71(6): 591-602.
3. Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation, 2015, 131(10): 927-964.
4. Mangano DT. Aspirin and mortality from coronary bypass surgery. N Engl J Med, 2002, 347(17): 1309-1317.
5. Jones WS, Mulder H, Wruck LM, et al. Comparative effectiveness of aspirin dosing in cardiovascular disease. N Engl J Med, 2021, 384(21): 1981-1990.
6. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(3): e4-e17.
7. Myles PS, Smith JA, Forbes A, et al. Stopping vs. continuing aspirin before coronary artery surgery. N Engl J Med, 2016, 374(8): 728-737.
8. Fox KA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation, 2004, 110(10): 1202-1208.
9. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol, 2011, 57(6): 672-684.
10. Jeppsson A, James S, Moller CH, et al. Ticagrelor and aspirin or aspirin alone after coronary surgery for acute coronary syndrome. N Engl J Med, 2025, 393(23): 2313-2323.
11. Zhao Q, Zhu Y, Xu Z, et al. Effect of ticagrelor plus aspirin, ticagrelor alone, or aspirin alone on saphenous vein graft patency 1 year after coronary artery bypass grafting: a randomized clinical trial. JAMA, 2018, 319(16): 1677-1686.
12. Sandner S, Redfors B, Angiolillo DJ, et al. Association of dual antiplatelet therapy with ticagrelor with vein graft failure after coronary artery bypass graft surgery: a systematic review and meta-analysis. JAMA, 2022, 328(6): 554-562.
13. Solo K, Lavi S, Kabali C, et al. Antithrombotic treatment after coronary artery bypass graft surgery: systematic review and network meta-analysis. BMJ, 2019, 367: l5476.
14. Zhu Y, Zhang W, Dimagli A, et al. Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial. BMJ, 2024, 385: e075707.
15. Yuan X, Li J, Lei L, et al. Efficacy of dual antiplatelet therapy for three months versus 12 months after coronary artery bypass grafting: multicentre, double blinded, randomised controlled trial. BMJ, 2026, 393: e088939.
16. Lamy A, Eikelboom J, Sheth T, et al. Rivaroxaban, aspirin, or both to prevent early coronary bypass graft occlusion: the COMPASS-CABG study. J Am Coll Cardiol, 2019, 73(2): 121-130.
17. Gaudino M, Di Franco A, Rong LQ, et al. Postoperative atrial fibrillation: from mechanisms to treatment. Eur Heart J, 2023, 44(12): 1020-1039.
18. van de Kar MRD, van Brakel TJ, Van't Veer M, et al. Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis. Eur Heart J, 2024, 45(29): 2620-2630.
19. Kulik A, Brookhart MA, Levin R, et al. Impact of statin use on outcomes after coronary artery bypass graft surgery. Circulation, 2008, 118(18): 1785-1792.
20. Campeau L, Enjalbert M, Lespérance J, et al. The relation of risk factors to the development of atherosclerosis in saphenous-vein bypass grafts and the progression of disease in the native circulation. A study 10 years after aortocoronary bypass surgery. N Engl J Med, 1984, 311(21): 1329-1332.
21. Domanski MJ, Borkowf CB, Campeau L, et al. Prognostic factors for atherosclerosis progression in saphenous vein grafts: the postcoronary artery bypass graft (Post-CABG) trial. J Am Coll Cardiol, 2000, 36(6): 1877-1883.
22. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J, 2020, 41(1): 111-188.
23. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J, 2021, 42(34): 3227-3337.
24. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2023, 148(9): e9-e119.
25. Eisen A, Cannon CP, Blazing MA, et al. The benefit of adding ezetimibe to statin therapy in patients with prior coronary artery bypass graft surgery and acute coronary syndrome in the IMPROVE-IT trial. Eur Heart J, 2016, 37(48): 3576-3584.
26. Goodman SG, Aylward PE, Szarek M, et al. Effects of alirocumab on cardiovascular events after coronary bypass surgery. J Am Coll Cardiol, 2019, 74(9): 1177-1186.
27. Ferguson TB, Coombs LP, Peterson ED, et al. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA, 2002, 287(17): 2221-2227.
28. Zhang H, Yuan X, Zhang H, et al. Efficacy of long-term β-blocker therapy for secondary prevention of long-term outcomes after coronary artery bypass grafting surgery. Circulation, 2015, 131(25): 2194-2201.
29. Bj?rklund E, Nielsen SJ, Hansson EC, et al. Secondary prevention medications after coronary artery bypass grafting and long-term survival: a population-based longitudinal study from the SWEDEHEART registry. Eur Heart J, 2020, 41(17): 1653-1661.
30. Rouleau JL, Warnica WJ, Baillot R, et al. Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery. Circulation, 2008, 117(1): 24-31.
31. Ruel M, Sun LY. Post-operative calcium-channel blocker use after radial artery grafting: do we now have a definitive answer? J Am Coll Cardiol, 2019, 73(18): 2307-2309.
32. Gaudino M, Benedetto U, Fremes SE, et al. Effect of calcium-channel blocker therapy on radial artery grafts after coronary bypass surgery. J Am Coll Cardiol, 2019, 73(18): 2299-2306.
33. Zhu Y, Zhang W, Qin K, et al. Effects of nicorandil, isosorbide mononitrate, or diltiazem on radial artery grafts after CABG: the randomized ASRAB-Pilot trial. Circ Cardiovasc Interv, 2025, 18(4): e014542.
34. Maddox TM, Januzzi JL, Allen LA, et al. 2024 ACC expert consensus decision pathway for treatment of heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol, 2024, 83(15): 1444-1488.
35. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2022, 145(18): e895-e1032.
36. McDonagh TA, Metra M, Adamo M, et al. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J, 2023, 44(37): 3627-3639.
37. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 2018, 138(13): e272-e391.
38. Kusumoto FM, Calkins H, Boehmer J, et al. HRS/ACC/AHA expert consensus statement on the use of implantable cardioverter-defibrillator therapy in patients who are not included or not well represented in clinical trials. Circulation, 2014, 130(1): 94-125.
39. Joseph JJ, Deedwania P, Acharya T, et al. Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: a scientific statement from the American Heart Association. Circulation, 2022, 145(9): e722-e759.
40. Verma S, Emerson S, Plutzky J, et al. Semaglutide improves cardiovascular outcomes in patients with history of coronary artery bypass graft and obesity. J Am Coll Cardiol, 2025, 85(5): 541-545.
41. Marx N, Husain M, Lehrke M, et al. GLP-1 receptor agonists for the reduction of atherosclerotic cardiovascular risk in patients with type 2 diabetes. Circulation, 2022, 146(24): 1882-1894.
42. Lincoff AM, Brown-Frandsen K, Colhoun HM, et al. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med, 2023, 389(24): 2221-2232.
43. Castagna MT, Mintz GS, Ohlmann P, et al. Incidence, location, magnitude, and clinical correlates of saphenous vein graft calcification: an intravascular ultrasound and angiographic study. Circulation, 2005, 111(9): 1148-1152.
44. Gaudino M, Sandner S, An KR, et al. Graft failure after coronary artery bypass grafting and its association with patient characteristics and clinical events: a pooled individual patient data analysis of clinical trials with imaging follow-up. Circulation, 2023, 148(17): 1305-1315.
45. Scheenstra B, van Susante L, Bongers BC, et al. The effect of teleprehabilitation on adverse events after elective cardiac surgery: a randomized controlled trial. J Am Coll Cardiol, 2025, 85(8): 788-800.
46. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation, 1999, 99(16): 2192-2217.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesInterpretation of the 2026 AHA Scientific Statement on Secondary Prevention After Coronary Artery Bypass Graft Surgery

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