The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Smokers who quit successfully after CABG are
rewarded with improved survival, improved graft
patency, less recurrent angina, fewer hospital admis-
sions, and better maintenance of employment over
persistent smokers [66]. In addition, persistent
smokers have more MIs and reoperations than those
who stop smoking [67].

Cardiac rehabilitation
Class I
Cardiac rehabilitation should be offered to all eli-
gible patients after CABG. (Level of Evidence: B)
Cardiac rehabilitation including early ambulation
during hospitalization, outpatient prescriptive exer-
cise training, family education, and sexual counsel-
ing have been shown to reduce mortality [1,68,69].
Outpatient rehabilitation beginning 4 to 8 weeks
after CABG and consisting of three-times weekly
educational and exercise sessions for 3 months is
associated with an improvement in exercise toler-
ance and cholesterol levels [70].

Special patient subsets

CABG in the elderly: age 70 and older
Elderly patients have a higher incidence of left main
disease, multivessel disease, LV dysfunction, and
reoperation as the indication for surgery, and for
many, concomitant valve surgery [1]. These patients
also have more comorbid conditions and increased
rates of fatal and nonfatal complications [71,72].
Operative mortality (%) is shown as a function of
age in Fig. 7.2. A higher operative mortality occurs
for all identifi ed risk factors in patients aged 75 years
or older than for those less than 65 [1]. Emergency
surgery in the elderly confers up to a 10-fold increase
in risk (3.5–35%), urgent surgery a 3-fold increase
(3.5–15%), hemodynamic instability a 3- to 10-fold
increase, and an LVEF <0.20 up to a 10-fold increase
[1]. OPCAB may be advantageous in high-risk
patients, particularly those with an LVEF less than
0.35 [73,74].
It should be emphasized that long-term survival
and functional improvement can be achieved in the
elderly patient despite severe cardiovascular disease
and an urgent indication for surgery [75]. The 5-
year survival of such patients who recover from
surgery is comparable to that of the general
population matched for age, sex, and race [76,77].

Preoperative variables associated with poor long-

term survival in elderly patients are atrial fi brilla-

tion, smoking, peripheral vascular disease, and poor

renal function, and an unsatisfactory functional

outcome has been infl uenced by hypertension, cere-

brovascular insuffi ciency, and poor renal function

[78]. Age alone should not be a contraindication to

CABG if it is concluded that long-term benefi ts out-

weigh the procedural risk [1,79].

CABG in women

In-hospital mortality and morbidity and long-term

survival after CABG appear related more to risk

factors and patient characteristics than to gender,

although some studies demonstrate increased risk

for female low- and moderate-risk patients [80].

Women may be particularly vulnerable to postop-

erative congestive heart failure, low cardiac output

syndrome [81–83], and blood loss [84]. However,

CABG should not be delayed or denied to women

who have the appropriate indication for revascular-

ization [1].

CABG in patients with diabetes

Patients with diabetes have a higher mortality after

MI and CABG than patients who do not have dia-

betes [1]. However, results from the BARI trial

showed that patients with multivessel CASHD who

were being for diabetes at baseline had a signifi cantly

better survival after CABG versus PTCA (Fig. 7.3)

Operative mortality %

8 7 6 5 4 3 2

40–49 50–59

1

60–6465–69

Age in years

(1.65)

70–7475–79 >80

2.17

2.76

3.36

5.28

8.31

Fig. 7.2 Operative mortality (%) for CABG in various age cohorts.

Data derived from Hannan et al. Am Heart J. 1994;128:1184–91.