Coronary artery bypass grafting (CABG) remains a key modality of revascularisation for both acute and chronic coronary syndromes. After CABG, antithrombotic therapy is at the cornerstone of the recommended cardiovascular pharmacotherapy. The aims of antithrombotic therapy after CABG are to maintain graft patency and reduce the risk of non-CABG-related atherothrombotic events. Balanced against this is the bleeding risk conferred by the treatment. Striking this balance is key to making the best recommendations for a CABG patient but can be challenging.
Now published is a welcome Clinical Consensus Statement on antithrombotic therapy after CABG, produced jointly by the ESC Working Groups on Cardiovascular Surgery and Cardiovascular Pharmacotherapy, and the European Association for Cardio-Thoracic Surgery (EACTS). This aims to help clinicians decide on the best, most evidence-based treatments for their CABG patients.

Aspirin remains central, with early reintroduction after surgery strongly recommended. For higher-risk patients, particularly those with acute coronary syndromes, dual antiplatelet therapy (DAPT) with aspirin and a reliable P2Y12 inhibitor is recommended. Some patients with chronic coronary syndromes who undergo CABG may also benefit from DAPT where bleeding risk is low. The consensus statement also addresses peri-operative management of P2Y12 inhibitors, noting the importance of discontinuation intervals and potential bridging strategies such as use of cangrelor.

Antithrombotic therapy in other aspects is discussed, including post-operative atrial fibrillation, where oral anticoagulation must be weighed against bleeding risk, and combined approaches like dual-pathway inhibition, the benefits of which are less certain in patients with CABG. Similarly, bleeding risk stratification tools such as WILL-BLEED (specific to CABG), ARC-HBR or PRECISE-DAPT may be helpful, though some limitations should be acknowledged.

Overall, the consensus statement emphasises individual-level decision making incorporating input from the multidisciplinary team to best balance the patient-specific ischaemic and bleeding risks. It also highlights areas where robust CABG-specific trial evidence is lacking and calls for further research into optimal combinations, dosing, and durations of therapy in this distinct population.