Management of Post Operative CABG Patients - A ReviewKhawaja Tahir Mahmood1, Attiya Khalid2, Saba Ali21Drug Testing Lab,2Department of Pharmacy, Lahore College for Women University.Abstract:CABG, abbreviation for coronary artery bypass graft is a type of surgery used to bypass a blockage in one of theblood vessels that supplies the muscle of the heart. The surgery involves cutting the affected coronary arteryabove and below the blockage, then attaching a small loop of vein (saphenous) or artery (mamillary) at each cut,creating a new circuit, or “bypass,” through which blood may flow. Mortality and complications increase withage (older than 70 years), poor heart muscle function, disease obstructing the left main coronary artery, diabetes,chronic lung disease, and chronic kidney failure. Coronary artery disease diagnosed by scanning angiography,cardiac catheterization, injecting thalium IV, Tissue Doppler stress echocardiography. Three commonly usedclasses of drugs are the nitrates, beta blockers and calcium blockers. Nitroglycerin (Nitro-Bid) is an example ofa nitrate. Unstable angina is also treated with aspirin and the intravenous blood thinner heparin. Aspirin preventsclumping of platelets, while heparin prevents blood clotting on the surface of plaques in a critically narrowedartery. Coronary artery bypass graft (CABG) surgery reestablishes sufficient blood flow to deliver oxygen and

nutrients to the heart muscle. In addition to healthy lifestyle changes, remember the importance of regularmedical checkups. Early detection and treatment can set the stage for a lifetime of better heart health.Key words :post operative CABG, cardiac catheterization, pleural effusion, electrocardiography, atrialfibrillation.INTRODUCTION:Coronary artery bypass graft surgery, alsoknown as CABG or bypass surgery, can help torestore blood flow to an area of the heart.However, surgery does not stop the progressionof atherosclerosis (coronary heart disease),which deposits fatty material into artery walls,narrowing them and eventually limiting bloodflow .Off-pump CABG (OPCABG) results inbetter preservation of left ventricular functionin the perioperative period than conventionalon-pump CABG (ONCABG). [1] CABG hasbeen routinely used to reduce angina andimprove chances of survival in patients withCAD. Since CABG became a recognizedstandard treatment of CAD, considerableevidence has accumulated concerning thepathogenesis of CAD; the efficacy, risks, andcosts of CABG; and the effectiveness of CADrisk factor reduction. [2]Clinical presentations of coronary arterydisease include silent ischemia, angina pectoris,acute coronary syndromes (unstable angina,MI), and sudden cardiac death. [3]RECOVERY SYMPTOMS:The most common recovery symptoms afterCABG were chest andleg incision pain, havingtrouble sleeping, and neck and shoulderor backdiscomfort. The most common mood states

wereconfusion, anxiety, andanger,respectively. In addition, Thai CABGpatientswho had more frequent recoverysymptoms also had greater negativemooddisturbance.[3]SIGNS AND SYMPTOMS:The most common signs and symptoms arechest pain or chest discomfort, heartpalpitations, lightheadedness or dizziness,syncope (fainting/loss of consciousness),fatigue, lethargy or daytime sleepiness,shortness of breath. Chest pain, squeezing,choking and discomfort in chest associatedwith pain in jaw head and arms is morecommon. Palpitations (irregular heart beat isanother major symptom). [4]CABG:CABG has been routinely used to reduceangina and improve chances of survival inpatients with CAD. Since CABG became arecognized standard treatment of CAD,considerable evidencehas accumulatedconcerning the pathogenesis of CAD; theefficacy, risks, and costs of CABG; and theeffectiveness of CAD risk factor reduction.Coronary artery bypass grafting (CABG) hasbeen shown to prolongthe life expectancy ofKhawaja Tahir Mahmood et al / Journal of Pharmaceutical Science and Technology Vol. 3 (1), 2011,456-461456

severalsubgroups

ofpatientswithcoronaryartery disease, including those withleft ventriculardysfunction. [5]PATHOPHYSIOLOGY:Coronary atherosclerosis is often irregularlydistributed in different vessels but typicallyoccurs at points of turbulence (eg, vesselbifurcations). As the atheromatous plaquegrows, the arterial lumen progressivelynarrows, resulting in ischemia (often causingangina pectoris). The degree of stenosisrequired to produce ischemia varies with O2demand the majority of left main stem stenosesare distal/ bifurcation lesions (at very high riskof restenosis with stents) and the majority ofpatients also have multivessel coronary arterydisease (for which CABG is already a superiortherapy to stents), the result is that for mostunprotected left main stem stenosis surgeryremains the standard of care. CABG is the'gold standard' therapy for significant left mainstem (LMS) stenosis because of the provensurvival benefit. [6]DIAGNOSTIC PROCEDURES:Non-invasive diagnosis of coronary arterydisease by quantitative stress echocardiographyis best performed using diagnostic modelsbased on segmental velocities at peak stress andadjusting for heart rate, and gender or age.Other techniques are Coronary arteriography ,injecting thallium IV, Tissue Doppler stressechocardiography,scanningangiography

,cardiaccatheterizationandECG:electrocardiography) may detect little, ifanything, abnormal between and sometimeseven during attacks of angina, even in peoplewith extensive coronary artery disease. Duringan attack, the heart rate may increaseslightly, blood pressure may go up, and with astethoscope, and doctors may hear a change inthe heartbeat. ECG may detect changes in theheart's electrical activity. When symptoms aretypical, the diagnosis is usually easy fordoctors. The kind of pain, its location, and itsassociation with exertion, meals, weather, andother factors help doctors make the diagnosis.The presence of risk factors for coronary arterydisease also helps establish the diagnosis. [7]RISK FACTORS:Exercise, diet, and tobacco use are the mostsignificant modifiable risk factorsThe presence of certain preoperative andpostoperativerisk factors can be predicted toprolong LOS after CABG surgery. Preoperativelength ofstay is more difficult to control.Therefore, attention hasbeen directed tocurtailing the postoperative length of stay. [8]Variousperioperative risk factors forpostoperative renal dysfunction and failurehave been identified. Among the importantpreoperative factors are advanced age, reducedleft ventricular function, and emergencysurgery, preoperative use of intraaortic balloonpump, elevated preoperative serum glucose andcreatinine. Most important intraoperative risk

factor is the intraoperative haemodynamicinstability and all the causes of postoperativelow output syndrome com prise thepostoperative risk factors. [9] Many factors arelinked with SSI at the sternum. Bone wax isfrequently used as a haemostatic agent toprevent oozing from cancellous bone. Althoughbacterial infection in this setting is infrequent,its occurrence is associated with increasedmorbidity and mortality. [10]Socioeconomic status was an importantfactor.Atrial fibrillation increased the total LOSin hospital after CABG. Atrial fibrillation is themost common arrhythmia occurring in patientsafter CABG. Identification of patients who areat risk for atrial fibrillation and successfultreatment to prevent atrial fibrillation is likelyto contribute to major reductions inconsumption of health care resources inpatients with CABG. [11]Female sex is reported to be an independentpredictor of length of stay in hospital. It seemsthat the most common causes of prolongedlength of stay in hospital in females are higherincidence of preoperative risk factors andpostoperative complications of CABG infemale than male. Therefore, it is important tocontrol these risk factors in female patientsbefore operation. [12], [13]Khawaja Tahir Mahmood et al / Journal of Pharmaceutical Science and Technology Vol. 3 (1), 2011,456-461457

COMPLICATIONS:1. Pleural effusion:More than 85% of patients develop pleural

effusions after coronary artery bypassgrafting (CABG). Although the majorityresolvesspontaneously,post-CABGeffusions can persist. The cause of thesepersistent effusions is unknown, and thehistology of the pleural changes has seldombeen reported. [14]2. Renal dysfunction:Renal dysfunction is common aftercoronary artery bypass graft (CABG)surgery.TheCABGprocedurescomplicated by stroke have a threefoldgreater peak serum creatinine level relativetouncomplicatedsurgery.However,postoperative creatinine patternsforprocedures complicated by cognitivedysfunction are unknown. Therefore, wetested the hypothesis that postoperativecognitive dysfunction is associated withacute perioperative renal injury after CABGsurgery. Data were prospectively gatheredfor 282 elective CABG surgery patients.Psychometric tests were performed atbaseline and 6 wk after surgery [15]3. Respiratory failure:There was an increase in respiratory failureafter coronary artery bypass graft (CABG)at Baptist Heart Institute during the first

three quarters of 2000. Thirteen percent ofpatients required ventilation over 24 hours.The reintubation rate after initial extubationwas 18.3% and the mortality rate in thegroup was 19.7%. After instituting anadvanced care team during the first threequarters of 2002, the prolonged ventilationrequirement was 7%; reintubation was4.2%, and the mortality rate 15.4%. Theseresults suggest that an advanced care teamcould improve clinical outcome and reducehealth care cost. [16]4. Atrial fibrillation:Atrial fibrillation and atrial flutter (AF)frequently complicate CABG .Studies ofdrug prophylaxis to prevent AF with β-adrenergic blocking agents administered infixed doses have had conflicting results.One hundred patients were randomized toreceive metoprolol or placebo followingCABG. There was no significant differencebetween the incidence of AF in themetoprolol (24%) and placebo (26%)groups. Metoprolol is not efficacious for theprevention of post-CABG AF even whendosage is titrated to achieve clinicalevidence of β blockade. It is likely that theadoption of a continuous cardioplegiatechnique caused a reduction in ourincidence of post-CABG AF. [17]MANAGEMENTPost CABG pain:Post-CABG pain (PCP) is a group of painsyndromes with a high prevalence, and with anegative effect on mood and performance ofdaily activities. The risk of developing PCP andits potential consequences should therefore be

discussed with every patient prior to CABGsurgery [18]Treatment:The treatment of patients with coronary arterydisease continues to evolve; all three strategies– medical therapy, surgical revascularization,and percutaneous coronary intervention – havechanged. Medical therapy with intense risk-factor modification and treatment with a statin,aspirin, and angiotensin-converting enzyme(ACE) inhibitors, should be used unlesscontraindicated. Surgical therapy has alsochanged with the introduction of minimallyinvasive, beating heart surgery. Percutaneouscoronary intervention has perhaps changed themost radically with adjunctive therapy –glycoproteinIIb/IIIainhibitors,thienopyridines,andrelianceonstentimplantation. [19].Antiplatelet therapy — Clopidogrel (Plavix®)and aspirin are antiplatelet medications that isgiven to help prevent the formation of bloodclots that can block the graft.Beta blockers — Beta blockers slow the heartrate, lower blood pressure, and decrease theheart's demand for oxygen.Nitrates — A nitrate, either as short-actingnitroglycerin, or as a long-acting preparation(isosorbide mononitrate or dinitrate). TheseKhawaja Tahir Mahmood et al / Journal of Pharmaceutical Science and Technology Vol. 3 (1), 2011,456-461

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drugs dilate coronary blood vessels, bringingmorebloodtotheheartmuscle.ACE inhibitor can reduce the incidence ofischemic events after CABG. Ischemic eventsincludedeath, repeatbypasssurgery,angioplasty or stent placement, heart attack,ischemic stroke, transient ischemic attack(TIA),orrecurrenceofangina.Lipid lowering therapy — almost all patientsare given a medication to lower lipids afterCABG. [20]CARE AT HOME AFTER BYPASSSURGERYCare after bypass surgery aims to reduce therisk factors for heart disease and includesstrategies to help patients and family membersto stop smoking, control high blood pressure,improve cholesterol levels, begin exercisingregularly, and reduce stress. Some of thesechanges can be made by adjusting lifestylehabits through diet and exercise. However,lifestyle changes alone may not be adequate

and medications are often needed. [20]CLINICAL SITUATIONS WHICHSHOULD ALERT ANESTHESIOLOGISTThe following examples should potentially alertanaesthesiologists regarding need to evaluateand provide further testing.1. Patients with acute coronary syndromes,such as un stable angina or decompensatedheart failure from ischaemia are at high riskof developing furtherdecompensation,myocardial infarction, and death during theperioperative period. Such patients shouldnot undergo non cardiac surgery.2. If surgery is emergent consider stabilizationbypharmacologicandmechanicalinterventions and proceed for surgerywithout delay. Consider risk stratification inthe postoperative period. Avoid furthertesting unless the results will impactperioperative management.3. Patients with critical aortic stenosis may beasymptomatic and evaluation of systolicejection murmur is warranted. Patients withcritical aortic stenosis may have a high riskof undergoing elective non cardiac surgery.4. Patients with dyspnea on mild exertion areat high risk of developing perioperativeventriculardysfunction,myocardialischaemia and MI. Consider additionalmonitoring and testing as they have highprobability of extensive CAD.

5. Watch for peripheral vascular disease asthey have a high association with CAD.[21]MONITORING OF CABG ASSOCIATIONThere are continuing reasons to monitor theassociationofCABGwithpossiblepostoperative cognitive change. First, thetechnologyassociated with CABG is constantlychanging, and the efficacyof these changes interms of cognitive outcomes should bedetermined.Second, there is increasing use ofother interventions for coronaryartery disease,such as "off-pump" CABG and coronaryartery stenting procedures. [22]CONCLUSIONHealth care system is designed to meet thehealth care needs of target population. Most ofthe CABG patients are hospitalized so it is theduty of health care providers to give bestmanagement of CABG related complicationsand it includes coagulopathy, systemicinflammatory response and perfusion to brain,kidney and liver. After CABG all patientsshould begin taking aspirin, and patients with ahistory of myocardial infarction should also begivena beta-blocker, unless itiscontraindicated. ACE inhibitors should be usedin high-risk patients. All patients should beencouraged to change their diet and pursue arehabilitation program involving exercise andstress management. Cessation of smoking isespecially important. Weight reduction mayalso be helpful. Statins should be used to

achieve targets for LDL cholesterol (preferablya level of 60 to 85 mg per deciliter, butcertainly less than 100 mg per deciliter). Inaddition, patients should be screened fordepression, since it is common and treatable.Depressed patients should be informed thattreatment of depression is likely to improvetheir ability to concentrate. So it has beenconcluded that pharmaceutical care plan isKhawaja Tahir Mahmood et al / Journal of Pharmaceutical Science and Technology Vol. 3 (1), 2011,456-461459

important to reduce the morbidity and mortalityand to increase the desired therapeuticoutcomes.RECOMMENDATIONSHeart disease can be improved — or evenprevented — by making certain lifestylechanges. The following changes can helpanyone who wants to improve their hearthealth: Pharmacists should more involve inmodifying patient behavior and physicianprescribing behaviors and practices. Pharmacist should told about, drug-druginteractions, incorrect drug dosage orduration of drug treatment, drug-allergyinteractions, clinical abuse ,the name anddescription of the medication, the route,dosage form, route of administration andduration of therapy. Stop smoking. Smoking is a major riskfactor for heart disease, especiallyatherosclerosis. Control blood pressure. Ask doctor for a

blood pressure measurement at least everytwo years. He or she may recommend morefrequent measurements if blood pressure ishigher than normal. Check cholesterol. Most people should aimfor an LDL level below 130 milligrams perdeciliter (mg/dL), or 3.4 millimoles per liter(mmol/L). Keep diabetes under control. If a person hasdiabetes, tight blood sugar control can helpreduce the risk of heart disease. Eat healthy foods. A heart-healthy dietbased on fruits, vegetables and whole grains— and low in saturated fat, cholesterol andsodium — can help to control weight, bloodpressure and cholesterol. Eating one or twoservings of fish a week also is beneficial. Manage stress. Reduce stress as much aspossible. Practice healthy techniques formanaging stress, such as muscle relaxationand deep breathing. Practice good hygiene habits. Staying awayfrom other people when they are sick andregularly washing your hands can not onlyprevent heart infections but also can helpprevent viral or bacterial infections that canput stress on your heart if you already haveheart disease. In addition to healthy lifestyle changes,remember the importance of regularmedical checkups. Early detection andtreatment can set the stage for a lifetime ofbetter heart health. Pharmacists are a useful source of help andadvice to any prescriber, particularly onmatters of pharmacology, drug usage andproduct selection in case of CABG so there

presence is necessary for effective drugtherapy.REFERENCES:[1].Cardiovascular News. Heart Views. 2008 .9 :2-5.[2].David K. Cundiff Coronary Artery BypassGrafting (CABG): Reassessing Efficacy,Safety, and Cost General Medicine, 20024 (2).[3].Ketsarin Utriyaprasit and Shirley MooreRecovery Symptoms and Mood States in ThaiCABG patients. Journal of transculturalnursing. 2005, 16: 97-106.[4].Richard N. Fogoros, MD Key Symptoms ofHeart Disease. 2009, 112 , 954-958[5].Christakis GT, Weisel RD, Fremes SE,Ivanov J, David TE, Goldman BS, SalernoTA. Coronary artery bypass grafting inpatients with poor ventricular function.JThorac Cardiovasc Surg. 1992, 103[6].Keogh BE, Kinsman R. Fifth national adultcardiac surgical database report 2003.Dendrite Clinical Systems. 2004, 130 , 348-352.[7].Maitra G, Ahmed A, Rudra A, Wankhede R,Sengupta S, Das T. Renal Dysfunction afterOff-Pump Coronary Artery Bypass Surgery-Risk Factors and Preventive Strategies.IndianJ

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Eisenberg E et al. Prevalence andcharacteristics of post coronary artery bypassgraft surgery pain ( PCP ). Pain.2009; 92 (1-2):11-7:[19].David R Holmes Jr Current Controlled Trialsin Cardiovascular Medicine. 2001; 2 :263-265[20].Julian M Aroesty, MD. Recovery aftercoronary artery bypass graft surgery ( CABG )03 February 2010 21 :40[21].Mangano DT, Goldman L. Preoperativeassessment of patients with known orsuspected coronary disease. 1995; 333 : 1750-6.[22].Barry SJ, Zeger SL, Selnes OA, et al.Quantitative methods for tracking cognitivechange 3 years after coronary artery bypasssurgery. 2005; 79 :1104-1109Khawaja Tahir Mahmood et al / Journal of Pharmaceutical Science and Technology Vol. 3 (1), 2011,456-461461