Frequency of Use of Statins and Aspirin in Patients With

Previous Coronary Artery Bypass Grafting

Kevin Curl, MDa,*, Bryan LeBude, MDb, Nicholas Ruggiero, MDa, David Fischman, MDa,
Andrew Rose, MDc, Sulay Patel, MDd, David Ogilby, MDa, Paul Walinsky, MDa, Babu Jasti, MDa, and
Michael Savage, MDa

Coronary artery bypass grafting (CABG) is commonly performed to treat ischemic heart
disease, but long-term benets are limited by failed patency of bypass grafts. Both statin
medications and aspirin hold class I indications for all post-CABG patients and should be
continued indenitely unless contraindications exist. Unfortunately, there are limited data
regarding long-term usage of these essential medications. We assessed the utilization rates
of statins and aspirin among post-CABG patients referred for coronary angiography.
Analysis of post-CABG patients presenting to Thomas Jefferson University for a cardiac
catheterization procedure at least 3 years after surgery was performed. Inpatient and
outpatient records were reviewed to assess prescribing patterns of these medications, as well
as other pertinent clinical and laboratory data. The study population was 381 consecutive
patients presenting at a mean of 11 6 years from CABG. Mean age was 69 11 years and
78% were men. A total 67% of patients were being prescribed a statin, whereas 75% were
prescribed aspirin. Only 52% were prescribed both at the time of catheterization. Patients
prescribed a statin had a signicantly lower mean low-density lipoprotein (87 vs 106 [p
<0.01]) and total cholesterol values (151 vs 162 [p <0.01]). A total of 35% of patients had
low-density lipoprotein 100. Only 43% of saphenous vein grafts in the patients not on
statin medications remained patent. In conclusion, long-term statin and aspirin use after
CABG remains suboptimal despite clear guideline recommendations and clinical trial ev-
idence of their effectiveness. 2016 Elsevier Inc. All rights reserved. (Am J Cardiol
2016;118:40e43)

Coronary artery bypass grafting (CABG) remains an
effective and essential therapy for ischemic heart disease.
The long-term benets, however, are limited by high rates
of bypass graft stenosis and occlusion.1,2 The benecial
effects of statins and aspirin usage after CABG have been
demonstrated by numerous trials.3e6 In the recently pub-
lished American Heart Association scientic statement on
secondary prevention after CABG surgery, the long-term
use of statins and aspirin are class Ia indications.7
Although many randomized trials have focused on the
effects of drug therapies on early postoperative graft
patency, few studies have examined the utilization of these
proven therapies in the longer term clinical setting.
Accordingly, the present study was undertaken to assess
the frequencies of statin and aspirin use in a consecutive
a
Division of Cardiology, Department of Medicine, Thomas Jefferson
University Hospital, Philadelphia, Pennsylvania; bDivision of Cardiology,
Department of Medicine, Washington Hospital Center, Georgetown
University Hospital, Washington, DC; cDepartment of Cardiology, Potts-
town Medical Associates, Pottstown, Pennsylvania; and dDivision of Car-
diology, Department of Medicine, Emory University, Atlanta, Georgia.
Manuscript received February 11, 2016; revised manuscript received and
accepted April 12, 2016.
All authors had access to the data and a role in writing the study.
See page 43 for disclosure information.
*Corresponding author: Tel: (1) 609-458-9256; fax: (1) 215-503-
3976.
E-mail address: kevin.curl@jefferson.edu (K. Curl).
series of patients who were referred for repeat cardiac
catheterization after previous CABG.
Methods
We performed a retrospective analysis of the medical and
electronic records in 381 consecutive patients with a history
of previous CABG surgery who underwent a diagnostic
cardiac catheterization at Thomas Jefferson University
Hospital for the rst time since their CABG. Patients were
identied through the cardiac catheterization laboratory
database. Data obtained included age, gender, a history of
CABG, medical co-morbidities, smoking status, current
medications (including statins and antiplatelet drugs), indi-
cation for catheterization, lipid panel, glomerular ltration
rate and angiographic ndings of the cardiac catheterization.
Angiographic analysis dened graft status as patent (<50%
stenosis), diseased (50% to 99% stenosis), and occluded
(100% stenosis) based on visual estimation. Exclusion
criteria constituted patients with CABG <3 years before the
index cardiac catheterization, absence of a lipid panel within
30 days before or 7 days after the index cardiac catheteri-
zation, and incomplete diagnosis of graft status by cardiac
catheterization. The Institutional Review Board of Thomas
Jefferson University Hospital approved this study.
Continuous variables are presented as mean
SD and
were analyzed using factorial analysis of variance. Cate-
gorical variables are displayed as a percentage and were
compared using chi-square statistics. We compared outcome

0002-9149/16/$ - see front matter 2016 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2016.04.006
 Coronary Artery Disease/Medication Underutilization Following Coronary Bypass Surgery 41

Table 1 LDL
Baseline patient characteristics (n 381)
Variable Mean
SD or %

Age (years) 69
11
Men 297 (78%) < 70
Diabetes mellitus 164 (43%)
21%
Hypertension 282 (74%)
100
Current Smoker 53 (14%)
Years Since Coronary Bypass 11
6 35%
Total Cholesterol (mg/dL) 156
43
Low Density Lipoprotein (mg/dL) 94
36
High Density Lipoprotein (mg/dL) 37
11
Triglyceride (mg/dL) 134
89 70-99
Glomerular Filtration Rate (mL/min/1.73 m2) 62
23 44%
Statin Use 255 (67%)
High Intensity 59 (23%)
Moderate Intensity 174 (68%)
Low Intensity 22 (9%) Figure 1. LDL control based on Adult Treatment Panel III8 guidelines.
Prior Intolerance to Statin 11 (3%)
Aspirin Use 286 (75%)
Clopidogrel Use 80 (21%)
Warfarin Use 51 (13%)
Clinical Indication for Cardiac Catheterization
ST-elevation Myocardial Infarction 19 (5%)
Non-ST-elevation Myocardial Infarction 100 (26%)
Unstable Angina Pectoris 141 (37%)
Chronic Angina Pectoris 36 (9%)
Abnormal Stress Test 50 (13%)
Heart Failure 30 (8%)
Aortic Valve Disease 5 (1%)

variables between patients grouped by their overall status of

grafted vessels and groups of grafted vessels. Statistical
analysis was performed using SPSS software, version 19
Figure 2. Utilization rates of statins, aspirin, and both medications at the
(IBM, Armonk, NY). A p value <0.05 was considered
time of cardiac catheterization.
signicant.

Results
Baseline clinical characteristics are depicted in Table 1.
The mean age of the study population was 69
11 years;
78% of patients were men and 43% were diabetic. The
median CABG age was 11
6 years; there were an average
of 2.9 grafts per patient, with 67% of the grafts being
saphenous vein grafts (SVGs). Indications for catheteriza-
tion included unstable angina (37%), noneST elevation
myocardial infarction (26%), and abnormal stress test (13%;
Table 1). Lipid analysis revealed a mean low-density lipo-
protein (LDL) of 94
36 mg/dl; 35% of patients had LDL
values 100 mg/dl and only 21% had LDL <70 mg/dl
(Figure 1). Utilization rates of statins and aspirin are shown
in Figure 2. At the time of the catheterization, 67% of
patients were taking a statin and 75% were taking aspirin
(Figure 2). Only 52% of patients were taking both aspirin
and a statin. A total of 21% were taking both clopidogrel in
addition to aspirin. Patient characteristics based on statin
and aspirin status are presented in Tables 2 and 3, respec-
tively. The mean total cholesterol and LDL values were
signicantly lower in the patients on statin therapy (Figure 3
and Table 2). Those not on statin therapy were more likely
to have LDL values 100 mg/dl (53% vs 26%, p
<0.001; Table 2).
Of the patients on a statin, 26% were found to have
patency of all SVGs compared with 25% of those who were
not taking a statin (p 0.867). There was no difference in
frequency of the different angiographic states (patent,
diseased, or occluded) based on statin usage. In patients
taking a statin, 46% of grafts were patent, 31% diseased, and
23% occluded, compared with 43% patent, 30% diseased,
and 27% occluded in patients not taking a statin (p 0.517).
Revascularization with percutaneous coronary intervention
or repeat CABG was performed in 62% of patients on statin
and 55% of patients not on statin (p 0.224).
Outcomes were also compared based on the use of
aspirin at the time of catheterization (Table 3). Patients on
aspirin were less likely to be taking warfarin (10% vs 32%;
p <0.001). There was no difference in the percent of pa-
tients with patent grafts according to aspirin usage (26% vs
26%) or in the frequency of the different angiographic states
(patent, diseased, or occluded). Among patients taking
aspirin at the time of catheterization, 46% of grafts were
patent, 30% diseased, and 24% occluded. For the patients
taking aspirin, 42% of SVGs were patent, 33% were
diseased, and 25% were occluded (p 0.703). Revascu-
larization was performed in 62% of patients on aspirin and
55% of patients not on aspirin (p 0.361).
42 The American Journal of Cardiology (www.ajconline.org)

Table 2
Clinical characteristics by statin status
Clinical Characteristic Statin Use r Value
Yes No
(n255) (n126)

Mean Age (Years) 69
10 71
9 0.265

Men 199 (78%) 101 (80%) 0.681
Acute Coronary Syndrome 161 (63%) 69 (55%) 0.175
Diabetes mellitus 120 (47%) 47 (37%) 0.127
Hypertension 194 (76%) 88 (70%) 0.276
Tobacco use 33 (13%) 20 (16%) 0.412
Aspirin 198 (78%) 91 (72%) 0.267
Dual Antiplatelet Therapy* 91 (24%) 20 (16%) 0.150
Mean Total Cholesterol (mg/dL) 151
35 162
49 0.024 Figure 3. Mean lipid values by statin status. All lipid values represented as
Mean Low Density Lipoprotein (mg/dL) 87
28 106
40 <0.001 mg/dl.
Mean High Density Lipoprotein (mg/dL) 37
11 34
11 0.091
Mean Triglyceride (mg/dL) 134
80 118
73 0.107 need for repeat revascularization.3,5 The landmark post-
Low Density Lipoprotein 100 (mg/dL) 66 (26%) 67 (53%) <0.001 CABG trial demonstrated that aggressive lipid management
Glomerular Filtration Rate 62
23 59
26 0.398 led to reduction in the incidence of new vein graft occlusions
(mL/min/1.73 m2) and the number of grafts with progression of atherosclerosis.6
Percutaneous Coronary Intervention 150 (59%) 66 (52%) 0.215 Data support initiating statin around the time of surgery,
Repeat CABG surgery 8 (3%) 4 (3%) 0.632
ideally preoperatively, and continuing therapy indenitely,
No Revascularization 97 (38%) 57 (45%) 0.224
unless contraindicated.5,6 Despite the strong evidence to sup-
Bold values highlight statistically signicant differences between groups. port statin therapy after CABG, the Synergy between PCI with
* Aspirin and clopidogrel. Taxus and Cardiac Surgery (SYNTAX) trial demonstrated that
only 75% of patients were prescribed a statin after surgery.10
Similar suboptimal rates have been demonstrated in other
Table 3
Clinical characteristics by aspirin status
studies.11,12 In the mid-1990s, Delacretaz13 found that in 245
patients who had elevated total cholesterol levels undergoing
Clinical Characteristic Aspirin Use r Value CABG or percutaneous coronary intervention, only 38% were
Yes No on lipid-lowering medications. In a retrospective cohort study
(n286) (n95) of more than 9,000 medicare patients treated from 1995 to
2004, only 35.9% received a statin within 90 days of hospital
Mean Age (Years) 70
10 70
9 0.868 discharge after CABG. The rates signicantly improved over
Men 226 (79%) 75 (79%) 0.957
time, from 13.1% in 1995 to 60.9% in 2004.12 Similar tem-
Acute Coronary Syndrome 174 (61%) 56 (59%) 0.873
Diabetes mellitus 126 (44%) 41 (43%) 0.906
poral trends in increased use of statin were demonstrated by
Hypertension 215 (75%) 66 (69%) 0.320 Newby et al. In a general population of patients with coronary
Tobacco use 37 (13%) 16 (17%) 0.347 artery disease, statin use increased from 25% in 1995 to 63% in
Statin Use 198 (69%) 57 (60%) 0.165 2002.14 In a time frame that extended beyond the previously
Clopidogrel Use 66 (23%) 15 (16%) 0.195 noted studies, our analysis revealed a small yet insignicant
Warfarin Use 29 (10%) 30 (32%) 0.001 increase in the utilization of statin therapy.
Mean Total Cholesterol (mg/dL) 155
41 153
38 0.620 The benecial effects of aspirin on SVG patency was rst
Mean Low Density Lipoprotein (mg/dL) 93
35 92
31 0.776 demonstrated in the 1980s.15 Preoperative aspirin has been
Mean High Density Lipoprotein (mg/dL) 36
12 35
10 0.404 shown to signicantly improve SVG patency rates and
Mean Triglyceride (mg/dL) 130
90 133
78 0.800
reduce operative morbidity and mortality.16,17 Johnson
Low Density Lipoprotein 100 mg/dL 103 (36%) 29 (31%) 0.517
Glomerular Filtration Rate 62
24 57
24 0.131
et al18 demonstrated a 42% reduction in the relative risk of
(mL/min/1.73 m2) death in post-CABG patients who consistently took aspirin
Percutaneous Coronary Intervention 166 (58%) 49 (52%) 0.334 over a 4-year period after surgery compared with patients
Repeat CABG 9 (3%) 3 (3%) 0.611 who did not. A meta-analysis of 17 randomized trials
No Revascularization 112 (39%) 43 (45%) 0.361 similarly showed aspirin signicantly reduced the odds of
graft occlusion during the rst year after CABG, leading to a
Bold values highlight statistically signicant differences between groups. recommendation of indenite use of aspirin post-
operatively.19 The strongest predictor of death in the
SYNTAX trial was a lack of aspirin prescription at hospital
Discussion
discharge.10 Several previous studies have examined the rate
This present study conrms the signicant underutilization of aspirin use in post-CABG patients. In one study with a
of both aspirin and statins in patients during long-term follow- mean of 5.6 years after CABG surgery, the rate of aspirin
up after CABG. Statins play a crucial role in reducing neo- use at hospital admission was 82%.20 Quality improvement
intimal formation and smooth muscle proliferation in SVGs.9 interventions that will increase aspirin prescription patterns
They have been shown to reduce all-cause mortality, prevent after CABG surgery have been the source of investigation
vein graft atherosclerotic disease progression, and decrease the with the emphasis on pay-for-performance indicators.21 Our
 Coronary Artery Disease/Medication Underutilization Following Coronary Bypass Surgery
ndings highlight the need for coordinated efforts in
educating health care providers and patients to improve
long-term medication usage in this high-risk population.
This present study provides further data supporting
inadequate use of statins and aspirin after CABG. A limi-
tation of the study is its retrospective design; as such, the
reasons for withholding aspirin and statin therapy were not
available. Another limitation was that the patient population
was preselected in regards to the need of a cardiac cathe-
terization based on clinical symptoms and therefore the graft
occlusion rates were high irrespective of drug therapy status.
The study does not address the utilization of aspirin and
statins in the general post-CABG population as only patients
referred for follow-up cardiac catheterization were assessed.
Disclosures
The authors have no conict of interest to disclose.
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