How is coronary artery disease (CAD) treated?
To treat angina, medications are used reduce the heart muscle demand for oxygen in order to compensate for the reduced blood supply. Three commonly used drugs classes are the nitrates, beta blockers and calcium blockers.
• Nitroglycerin (Nitro-Bid) is an example of a nitrate.
• Propranolol (Inderal) and atenolol (Tenormin) are some beta blockers
• Nicardipine (Cardene) and nifedipine (Procardia, Adalat) are calcium blockers
Unstable angina is also treated with the intravenous blood thinner heparin and aspirin. Heparin prevents blood clotting on the surface of plaques in a critically narrowed artery, while aspirin prevents clumping of platelets.
Your doctors may indicate a coronary arteriography if you continue to have angina even after taking maximum medications or when significant ischemia still occurs when you exercise. During coronary arteriography, data is collected to help your doctor decide whether your should be considered for percutaneous coronary intervention or percutaneous transluminal angioplasty (PTCA). In angioplasty PTCA, a small balloon is used to inflate the blockage in your artery. The placement of a stent or coronary artery bypass graft surgery (CABG) — like that Mr. Clinton had undergone — usually follows angioplasty (PTCA).
But angioplasty also can produce excellent results in some patients. This involves inserting a wire from the groin to the coronary artery, under x-ray guidance. A small catheter with a balloon at the end is threaded over the wire to reach the narrowed segment, and the balloon is then inflated to push the artery open. Then a steel mesh stent is inserted.
If you are among the patients who have failed medical therapy and are not good candidates for angioplasty (PTCA), CABG surgery is the final solution performed to relieve angina. If you have significant narrowing of the left main coronary or narrowing in more than one arteries, you will find that CABG surgery improves your long-term survival, especially if you also experience decreased heart muscle pump function.
How is CABG surgery done?
In most cases, bypass surgery is open-chest surgery, so if you’re going to get one, you’ll be given anesthesia to make you sleep.
During the surgery, your chest will be open and your heart exposed. The cardiac surgeon makes a large cut — or incision — in the middle or side of your chest; he or she may saw through your breastbone and spread apart your rib cage.
To minimize damage caused by reduced blood flow during surgery, your heart will be cooled with iced salt water and a preservative solution is injected into your heart arteries. This surgery is called cardioplegia.
A cardiopulmonary bypass is done before bypass surgery is conducted: Plastic tubes are placed in the heart’s right atrium to channel venous blood out of your body. This is then passed through a plastic sheeting or membrane oxygenator in the heart lung machine. Oxygenated blood is then returned to the body. During CABG surgery, the main aorta is clamped off to maintain a bloodless field and to allow bypasses to be connected to the aorta.
Healthy blood vessels — often from your leg — are removed and attached or grafted to the blocked artery. The new blood vessel is sewn from the coronary arteries to the aorta, bypassing the blocked artery, to increase blood flow to your heart. You may need just one bypass graft or you may need more. The number of grafts you need depends on how many arteries are blocked and where. Some people will need as many as two, three, or even four — called a double, triple, or quadruple bypass surgery. The surgery can take three to six hours.
Usually, the saphenous vein from the leg is used. But surgeons are increasingly using chest wall arteries — particularly the left internal mammary artery — in CABGs. Using internal mammary arteries can be better because they tend to remain open longer than venous grafts. Ten years after CABG surgery, only 66 percent of vein grafts are open compared to 90 percent of internal mammary arteries. But artery grafts are of limited length and can only be used to bypass narrowing found near the beginning of the coronary arteries. Also, because of the extra time needed to separate these arteries from the chest wall, using these may prolong CABG surgery and can’t be used for time-critical emergency CABG surgery.
When the surgery is complete, the doctor may use wire to put your rib cage back together and stitches to close the incision. Plastic tubes are left in place to allow drainage of any remaining blood from the space around the heart. About five percent of patients require exploration within the first 24 hours because of continued bleeding after surgery. A day after surgery, the chest tubes are removed. But usually, the breathing tube is removed shortly after surgery.
A day after surgery, you may be able to get out of bed and can be transferred out of intensive care. Up to 25 percent of patients develop heart rhythm disturbances within the first three or four days after CABG surgery. But these are usually temporary atrial fibrillation that respond to standard medical therapy that can be weaned one month after surgery.
You will stay in the hospital at least three to eight days after the surgery. It can take four to six weeks to recover at home. Most people are able to return to work within one to two months after surgery.
In the traditional heart surgery, surgeons stop the heart from beating and pump blood through the body with a heart-lung machine. But a new advance for many patients is the ability to do CABG without going on cardiopulmonary bypass –“off pump” — with the heart still beating.
Called beating-heart surgery, Mr. Clinton went through this type because it significantly lowers the risk for stroke and minimizes the memory defects and other cognitive problems associated with bypass. Subtler benefits may exist among patients in Clinton’s age group as well, said Dr. Paul Corso, chief of cardiac surgery at Washington Hospital Center, but the issue was still being studied.
How do patients recover after CABG surgery?
After your discharge, recovery at home begins. Recovery includes physical therapy, respiratory therapy, occupational therapy, and diet counseling.
• After about seven to 10 days: sutures are removed from the chest prior and from the leg
• For four to six weeks, recovery happens
• During the first four to six weeks: swelling (edema) in the affected ankle will happen, if the vein was taken from here. If so, you will be advised to wear elastic support stockings during the day and to keep your leg elevated when sitting.
• After about six weeks: breastbone will heal
• In six to eight weeks: This swelling usually resolves.
What can you do and not do during recovery?
• Don’t lift anything more than 10 pounds or perform heavy exertion during this healing period.
• Don’t drive for the first four weeks to avoid any injury to the chest.
• Do return to normal sexual activity — as long as positions that put significant weight on the chest or upper arms are reduced.
• Do resume exercise and driving two to three weeks after the recovery period.
• Do know that you may experience heightened emotions — like a greater tendency to cry or otherwise show emotion in ways that are unusual compared with before the procedure — for up to a year following surgery.
• Do know that you can return to work within one to two months, depending on the type of work they do.
Cardiac rehabilitation program
Four to six weeks after CABG surgery, an exercise stress test is done, signaling the beginning of a cardiac rehabilitation program.
This rehabilitation consists of a 12-week program meant to get you to increase your exercise gradually to a point where you can exercise one hour three times a week.
What are the risks and complications of CABG surgery?
• Death. Two out of 100 people who have bypass surgery will have a serious complication that leads to death.
• Heart attack. One out of 100 people who have bypass surgery will have a heart attack soon after the surgery.
• Stroke. Three out of 100 people who have the surgery will have a stroke.
• Too much bleeding. Three to five out of 100 people who have the surgery will need a transfusion.
• Other risks: return of angina, infections at the site of the chest incision, problems from anesthesia, memory loss and trouble thinking clearly. These problems tend to improve several months after surgery and are common in older patients.
Mortality and complications increase with:
• age (older than 70 years)
• poor heart muscle function
• disease obstructing the left main coronary artery,
• diabetes
• chronic kidney failure
• chronic lung disease
Mainly because of their advanced age at the time of CABG surgery and smaller coronary arteries, mortality may be higher in women. Women develop coronary artery disease about 10 years later than men because of hormonal “protection” while they still regularly menstruate
How well does bypass surgery work?
Bypass surgery reduces angina and other symptoms of coronary artery disease:
• About 95 out of 100 people who have the surgery get relief from chest pain right away.
• Five years after surgery, more than 80 people out of 100 are still free of chest pain.
• People who have bypass surgery tend to have longer relief from repeat heart problems compared to people who have other treatments.
Bypass surgery can increase your chances of living a longer life: More than 90 people out of 100 who have a bypass are still alive five years after surgery.
How long a bypass lasts depends on how long the blood vessel grafts stay open:
• After five years, about two out of 100 people need another surgery.
• After 10 years, seven out of 100 people need another surgery.
But the success of CABG also depends on you. To get the most benefit from bypass surgery, you should:
• Stop smoking
• Eat right
• Get regular exercise
• Take medicines for angina
• Lower cholesterol
• Control blood pressure
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Famous People Who Had Heart Bypass Surgery: Bill Clinton. Posted 20 March 2012.