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Preparing for coronary artery bypass surgery

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If you have recently been diagnosed with a heart attack, stable angina or severe coronary artery disease (CAD), you may be facing open heart surgery for surgical revascularization (aka bypass surgery or CABG). In some cases, patients are rushed immediately from the cardiac catheterization lab directly to the operating room. For the majority of patients, it is better and safer to schedule surgery on an elective (non-urgent) basis.

Elective surgery is better than emergent surgery

While this delay from diagnosis to surgical treatment can be anxiety-producing for patients and their families, it is also an excellent opportunity to prepare for surgery and ‘life after bypass surgery’. There are volumes of information about coronary artery disease, cardiac surgery and post-operative recovery available for patients from well-respected sources such as the American Heart Association and the Centers for Disease Control (CDC).

General facts about Coronary Artery Bypass Surgery (CABG)

- In the United States, almost 400,000 bypass surgeries are performed every year (CDC statistics, 2013).

- Despite an increasing number of patients with serious co-morbidities such as diabetes and renal failure, post-operative mortality (death after surgery) has decreased over the last 20 years to 2.5 - 3.3% overall (Society of Thoracic Surgeons Cardiac Database, 2014).

- According to multiple studies including the SYNTAX trial, for the majority of patients with multi-vessel or left main disease, surgery is the safer and more durable option when compared to stents, angioplasty or medications alone.

- Many patients are discharged home 3 to 5 days after bypass surgery.

Preparing for the office consultation

Education:

- Bring a family member with you to ask questions and take notes.

- If you do not receive a written set of pre-operative instructions, ask for one.

- Bring a list of questions. Having surgery can be stressful and without a list, many people forget to ask important questions during their surgical consultation.

- Most cardiac surgery programs have a patient education department. This ‘mini-college’ will provide patients with a large quantity of information in the days immediately after surgery along with videos, books and other materials on coronary artery disease, cardiac rehabilitation, heart healthy cooking, resuming sexual activity after surgery, and post-operative medications. The sheer amount of information can sometimes be overwhelming for patients. The cardiac surgery process can also make patients a bit forgetful in the first few days and weeks after surgery so it is better to plan to have at least one family member or friend present for these educational sessions.

Medications:

- Bring a bag containing all of your current medications including herbal medications, over-the-counter drugs and vitamin supplements. If there are any medications that you are currently prescribed but are not taking (for any reason) be sure to discuss this with your surgeon as well, so these medications are not restarted by accident.

- Be sure to inform your doctor of any anti-coagulants and blood thinners you may be taking such as prasugrel (Effient), clopidogrel (Plavix), warfarin (Coumadin), ticagrelor (Brilinta), pentoxifylline (Trental) or cilostazol (Pletal). These medications can cause serious and even life-threatening bleeding so most surgeons will want you to discontinue these medications 5 to 7 days before surgery. However, it depends on the reason these medications have been prescribed and the severity of your coronary artery disease. The majority of surgeons will want you to continue your aspirin.

-Ask about your blood pressure medications and other cardiac medications. Many surgeons will want you to continue beta-blockers such as carvedilol (Coreg), metoprolol or atenolol before surgery to prevent post-operative arrhythmias. Your surgeon may want you to stop taking ace-inhibitors such as lisinopril, fosinopril or enalapril prior to surgery to prevent low blood pressure during anesthesia induction.

- Most surgeons will also want you to continue your statin medications before surgery. Several studies have shown these medications may prevent intra-operative complications such as stroke, and reduce post-operative inflammation.

- If you have diabetes, ask your doctor for specific instructions regarding your oral medications and insulins. Many of the newer diabetes medications may pose risk of increased cardiac complications or cause hypoglycemia during surgery. Other medications like metformin can cause other problems after surgery.

Most doctors manage hyperglycemia during surgery and after surgery with intravenous (regular) insulin infusions, which are easy to titrate to the patient’s fluctuating blood sugar. Patients are then transitioned to subcutaneous injections and oral medications as needed.

Past medical history:

- Be sure to mention if you have ever had a previous stroke (CVA) or mini-stroke (TIA). Many patients who have CAD also have carotid artery disease which can increase the risk of having a stroke during surgery. The doctor may want to order a carotid duplex (ultrasound) to see if there is a large amount of plaque in the carotid arteries leading to the brain.

- Discuss all previous surgeries, blood transfusions or radiation treatments. Be sure to mention if you or any immediate blood relatives have had problems with anesthesia, or developed a bleeding disorder or blood clots.

- Review medication, food and seasonal allergy information with your physician.

Health care proxies and patient privacy issues

- Be sure to designate a health care proxy. (This is important for all patients entering the hospital, not just surgery patients.) This person can help make decisions about your care when you are unable to do so, like during the period when you are recovering from anesthesia and/ or are intubated and unable to speak. Your health care proxy may also serve as your family representative to share information with other family members and friends.

- Discuss how and who you want (or don’t want) your medical information shared with during hospitalization. This includes post-operative visitation while you are in the intensive care unit. If you do not want your neighbors, friends, co-workers or church congregation to see you in the intensive care unit after surgery while you are unconscious, intubated, with a Foley catheter draining your bladder, now is the time to say so.

Work/ Finances/ Insurance

- Talk to your employer about medical leave and short-term disability paperwork. Your spouse or loved ones may want to apply for Family Medical Leave (FMLA), as well to stay with you in the immediate days after discharge from the hospital, and to take you to your doctor’s appointment. Give copies of all paperwork to the secretaries or administrators at the doctor’s office. They will be able to assist you in completing these forms.

- If you do not have insurance, or your coverage is poor, talk to the administrators and the hospital financial office about making payment arrangements or other financial matters. This will help alleviate stress prior to surgery.

Other:

- If you smoke, discuss smoking cessation with your surgeon.

- Review pre-operative activity restrictions with your surgeon. If you have frequent angina (chest pain), your surgeon may want you to refrain from vigorous activities before your surgery.

What if I have chest pain before surgery?

- Ask what to do if you experience increased episodes of chest pain (or chest pain equivalents) prior to surgery. Many surgeons will want you to come directly to the hospital. The doctors may want to start intravenous medications such as nitroglycerin or heparin to prevent additional heart damage as you prepare for surgery. Your surgery may be re-classified as “urgent” and scheduled sooner. This is important because sometimes patients have heart attacks at home waiting for surgery because they “didn’t want to bother anyone since I was scheduled for surgery anyway.”

While this is not an all-inclusive checklist for patients having heart surgery, it will help prepare you for bypass surgery and serve as a guide in discussing expectations with your surgeon and surgical team.

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