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Cardiac Rehabilitation: Improving Function and Reducing Risk.
Servey, JT, Stephens, M
American family physician. 2016;(1):37-43
Abstract
Cardiac rehabilitation is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. The overall goals focus on improving daily function and reducing cardiovascular risk factors. Cardiac rehabilitation includes interventions aimed at lowering blood pressure and improving lipid and diabetes mellitus control, with tobacco cessation, behavioral counseling, and graded physical activity. The physical activity component typically involves 36 sessions over 12 weeks, during which patients participate in supervised exercise under cardiac monitoring. There are also intensive programs that include up to 72 sessions lasting up to 18 weeks, although these programs are not widely available. Additional components of cardiac rehabilitation include counseling on nutrition, screening for and managing depression, and assuring up-to-date immunizations. Cardiac rehabilitation is covered by Medicare and recommended for patients following myocardial infarction, bypass surgery, and stent placement, and for patients with heart failure, stable angina, and several other conditions. Despite proven benefits in mortality rates, depression, functional capacity, and medication adherence, rates of referral for cardiac rehabilitation are suboptimal. Groups less likely to be referred are older adults, women, patients who do not speak English, and persons living in areas where cardiac rehabilitation is not locally available. Additionally, primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons.
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HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass.
Lewicki, M, Ng, I, Schneider, AG
The Cochrane database of systematic reviews. 2015;(3):CD010480
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Abstract
BACKGROUND Acute kidney injury (AKI) is common in patients undergoing cardiac surgery among whom it is associated with poor outcomes, prolonged hospital stays and increased mortality. Statin drugs can produce more than one effect independent of their lipid lowering effect, and may improve kidney injury through inhibition of postoperative inflammatory responses. OBJECTIVES This review aimed to look at the evidence supporting the benefits of perioperative statins for AKI prevention in hospitalised adults after surgery who require cardiac bypass. The main objectives were to 1) determine whether use of statins was associated with preventing AKI development; 2) determine whether use of statins was associated with reductions in in-hospital mortality; 3) determine whether use of statins was associated with reduced need for RRT; and 4) determine any adverse effects associated with the use of statins. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 13 January 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared administration of statin therapy with placebo or standard clinical care in adult patients undergoing surgery requiring cardiopulmonary bypass and reporting AKI, serum creatinine (SCr) or need for renal replacement therapy (RRT) as an outcome were eligible for inclusion. All forms and dosages of statins in conjunction with any duration of pre-operative therapy were considered for inclusion in this review. DATA COLLECTION AND ANALYSIS All authors extracted data independently and assessments were cross-checked by a second author. Likewise, assessment of study risk of bias was initially conducted by one author and then by a second author to ensure accuracy. Disagreements were arbitrated among authors until consensus was reached. Authors from two of the included studies provided additional data surrounding post-operative SCr as well as need for RRT. Meta-analyses were used to assess the outcomes of AKI, SCr and mortality rate. Data for the outcomes of RRT and adverse effects were not pooled. Adverse effects taken into account were those reported by the authors of included studies. MAIN RESULTS We included seven studies (662 participants) in this review. All except one study was assessed as being at high risk of bias. Three studies assessed atorvastatin, three assessed simvastatin and one investigated rosuvastatin. All studies collected data during the immediate perioperative period only; data collection to hospital discharge and postoperative biochemical data collection ranged from 24 hours to 7 days. Overall, pre-operative statin treatment was not associated with a reduction in postoperative AKI, need for RRT, or mortality. Only two studies (195 participants) reported postoperative SCr level. In those studies, patients allocated to receive statins had lower postoperative SCr concentrations compared with those allocated to no drug treatment/placebo (MD 21.2 µmol/L, 95% CI -31.1 to -11.1). Adverse effects were adequately reported in only one study; no difference was found between the statin group compared to placebo. AUTHORS' CONCLUSIONS Analysis of currently available data did not suggest that preoperative statin use is associated with decreased incidence of AKI in adults after surgery who required cardiac bypass. Although a significant reduction in SCr was seen postoperatively in people treated with statins, this result was driven by results from a single study, where SCr was considered as a secondary outcome. The results of the meta-analysis should be interpreted with caution; few studies were included in subgroup analyses, and significant differences in methodology exist among the included studies. Large high quality RCTs are required to establish the safety and efficacy of statins to prevent AKI after cardiac surgery.
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Diet and exercise interventions following coronary artery bypass graft surgery: a review and call to action.
Coyan, GN, Reeder, KM, Vacek, JL, Coyan, GN, Reeder, KM, Vacek, JL
The Physician and sportsmedicine. 2014;(2):119-29
Abstract
Coronary artery bypass graft (CABG) surgery has been used for the treatment of coronary artery disease (CAD) for approximately 50 years, and has been performed on millions of people globally. However, little is known about the impact of diet and exercise on long-term outcomes of patients who have undergone CABG surgery. Although clinical practice guidelines on the management of this patient population have been available for approximately 2 decades, evidence regarding secondary prevention behavioral interventions, lifestyle modifications and self-management to slow the progressive decline of CAD, reduce cardiac hospitalizations, and prevent reoperation remains virtually absent from the literature. Diet and exercise are modifiable factors that affect secondary CAD risk. This article reviews the relevant current literature on long-term diet and exercise outcomes in patients who underwent CABG. The limited available literature shows the positive impacts of exercise on psychosocial well-being and physical fitness. Current evidence indicates diet and exercise interventions are effective in the short-term, but effects fade over time. Potential age and sex differences were found across the reviewed studies; however, further research is needed with more rigorous designs to replicate and confirm findings, and to define optimal management regimens and cost-effective prevention strategies.
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Acute kidney injury associated with rhabdomyolysis after coronary artery bypass graft: a case report and review of the literatures.
Sudarsanan, S, Omar, AS, Pattath, RA, Al Mulla, A
BMC research notes. 2014;:152
Abstract
BACKGROUND Post-operative rhabdomyolysis is a well-known complication, especially after bariatric and orthopaedic surgeries. There are few published reports of rhabdomyolysis following cardiac surgery. Acute kidney injury had been distinguished as a serious complication of cardiac surgery. We report a case of 55-years-old male patient who developed rhabdomyolysis precipitated acute kidney injury after coronary artery bypass graft. CASE PRESENTATION The patient underwent urgent coronary artery bypass graft surgery, with a long duration of surgery due to technical difficulty during grafting. He developed rhabdomyolysis induced acute kidney injury necessitating hemodialysis. The patient in turn developed heart failure, which along with acute kidney injury lead to prolonged ventilation. There was supervening sepsis with prolonged intensive care unity stay and eventually prolonged hospitalization. The peak creatine kinase level was 39,000 IU/mL and peak myoglobin was 40,000 ng/ml. Reviewing the patient, surgery was prolonged due to technical difficulties encountered during grafting, leading to rhabdomyolysis induced acute kidney injury. The pre-operative use of statins by the patient could also have contributed to the development of rhabdomyolysis. He developed post-operative right heart failure and sepsis. The patient's renal function gradually improved over 4 week's duration. Favorable outcome could be achieved but after prolonged course of renal replacement therapy in the form of hemodialysis. CONCLUSION Prolonged duration of surgery is a well-recognized risk factor in the development of rhabdomyolysis. Early recognition of rhabdomyolysis induced acute kidney injury is important in reducing the post-operative morbidity and mortality in patients. A protocol based approach could be applied for early recognition and management.
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[Atrial fibrillation after coronary artery bypass surgery: possibilities of prevention].
Obrenović-Kirćanski, B, Orbović, B, Vraneš, M, Parapid, B, Kovačević-Kostić, N, Velinović, M, Ristić, S
Srpski arhiv za celokupno lekarstvo. 2012;(7-8):521-7
Abstract
Atrial fibrillation occurs as a frequent complication after cardiac interventions. It can be found in 5% of all surgical patients, and it is far more common in cardiac (10% - 65% of patients) than in non-cardiac procedures. In a number of patients it remains asymptomatic, but may be accompanied by very severe symptoms of hypotension, heart failure, syncope, systemic or pulmonary embolism, perioperative myocardial infarction, cerebrovascular insult and increased operative mortality. Patients whose postoperative course is complicated by atrial fibrillation require longer hospitalization. Possible predisposing factors of this arrhythmia are numerous and are associated with surgery, extensive coronary heart disease and revascularization, and preoperative diseases. According to the recommendations of the European Society of Cardiology orally applied beta-blocker, amiodarone and sotalol can be used for prophylaxis of atrial fibrillation. Following the recommendations, treatment of postoperative atrial fibrillation should include beta-blockers, amiodarone, and in patients with heart failure and left ventricular dysfunction, digoxin. Due to the increased risk of stroke, an anticoagulant protection is necessary. Many studies have been conducted with results supporting the prophylactic use of amiodarone and beta-blockers, while the treatment with new agents such as magnesium, statins, omega-3 fatty acids and inhibitors of the renin-angiotensin-aldosterone system is still being investigated.
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Effect of perioperative glucose-insulin-potassium infusions on mortality and atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis.
Rabi, D, Clement, F, McAlister, F, Majumdar, S, Sauve, R, Johnson, J, Ghali, W
The Canadian journal of cardiology. 2010;(6):178-84
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Abstract
BACKGROUND Glucose-insulin infusions (with potassium [GIK] or without [GI]) have been advocated in the setting of coronary artery bypass graft (CABG) surgery to optimize myocardial glucose use and to minimize ischemic injury. OBJECTIVE To conduct a meta-analysis assessing whether the use of GIKGI infusions perioperatively reduce in-hospital mortality or atrial fibrillation (AF) after CABG surgery. METHODS Electronic databases (Medline, EMBASE and Cochrane Central Register of Controlled Trials [CENTRAL]) and references of retrieved articles were searched for randomized controlled trials that evaluated the effects of GIK or GI infusions, before or during CABG surgery, on in-hospital mortality andor postoperative AF. Pooled ORs and 95% CIs were calculated for each outcome. RESULTS Twenty trials were identified and eligible for review. The summary OR for in-hospital mortality was 0.88 (95% CI 0.56 to 1.40), based on 44 deaths among 2326 patients. While postoperative AF was a more frequent outcome (occurring in 519 of 1540 patients in the 10 trials reporting this outcome), the overall pooled estimate of effect was nonsignificant (OR 0.79, 95% CI 0.54 to 1.15). This latter finding needs to be interpreted cautiously because it is accompanied by significant heterogeneity across trials. CONCLUSIONS Perioperative use of GIKGI does not significantly reduce mortality or atrial fibrillation in patients undergoing CABG surgery. Unless future trial data in support of GIKGI infusions become available, the routine use of these treatments in patients undergoing CABG surgery should be discouraged because the safety of these infusions has not been systematically examined.
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Radial artery as a graft for coronary artery bypass grafting.
Kobayashi, J
Circulation journal : official journal of the Japanese Circulation Society. 2009;(7):1178-83
Abstract
The radial artery (RA) graft was revived in late 1980 s when it was found that the graft was patent 13-18 years after coronary artery bypass grafting (CABG) after improvement of the technique in harvesting and the use of calcium-channel blockers. Recently, the RA became a reasonable alternative to the saphenous vein (SV) graft with the trend toward complete arterial revascularization and more frequent off-pump CABG to avoid aortic manipulation. To improve the quality of the RA conduit, harvesting technique and topical and systemic antispasmodic medication are important. The RA should be grafted to severe proximal stenosis (>90%) in the native coronary arteries to avoid flow competition, especially in the right coronary territory. The RA graft could be used as an aortocoronary or composite configuration with similar graft patency. Early graft patency of the RA conduit was as good as other arterial grafts, and better than SV graft in the circumflex and right coronary territories, in many studies, especially in diabetic patients. Long-term results of graft patency and cardiac-event-free survival compared with SV graft are still controversial in randomized controlled trials, probably because the incidence of flow competition and the definition of graft patency varied.