From Up To Date... The home health care plan for the patient recovering from bypass surgery focuses on
- wound healing,
- managing new and changed medications,
- cardiac rehabilitation & exercise,
- reducing risk factors.
1. Wound care
On discharge the patient receives instructions on how to care for chest and/or leg wounds. In addition, home care clinicians should remind the patient to avoid heavy lifting and extremes of shoulder movement (eg, as in tennis, baseball, and golf) for six to eight weeks after surgery to allow for complete healing of the breast bone (sternum).
Additionally the patient should contact the physician for any signs of infection:
- Fever greater than 100.4º F (38º C)
- New or worsened pain in the chest or around the incision
- A rapid heart rate
- Reddened skin, bleeding or pus-like drainage from the incision
2. Common Medications Ordered Post-CABG
- Antiplatelet therapy – Aspirin is frequently ordered to help prevent the formation of blood clots that can block either coronary arteries or coronary bypass graft. It is usually recommended indefinitely.
- Beta blockers – Beta blockers slow the heart rate, lower blood pressure, and decrease the heart's demand for oxygen. They are given to some patients with high blood pressure, heart failure, some rhythm changes or a heart attack, and to some patients in whom bypass surgery is not expected to relieve all symptoms of angina. If a person cannot tolerate a beta blocker, a calcium channel blocker may be substituted.
- Nitrates – A nitrate, either as short-acting nitroglycerin, or as a long-acting preparation (isosorbide mononitrate or dinitrate). These drugs dilate coronary blood vessels, bringing more blood to the heart muscle. Nitrates also reduce the amount of blood returning to the heart, which decreases the heart's demand for oxygen. Nitrates are often given to treat or prevent further episodes of chest pain. Nitrates may be given to patients after bypass surgery if some of the coronary blood vessels could not be bypassed.
- ACE inhibitor – Angiotensin converting enzyme (ACE) inhibitors are often used to treat high blood pressure. Examples of ACE inhibitors include captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril or Prinivil), and ramipril (Altace). Some patients who cannot tolerate an ACE inhibitor (often because of a chronic cough) may be prescribed an angiotensin II receptor blocker (ARB). These related drugs are satisfactory replacements. Examples of ARBs include losartan (Cozaar), valsartan (Diovan), and irbesartan (Avapro).
- Lipid-lowering therapy – Almost all patients are given a medication to lower lipids after CABG. Cholesterol lowering can be beneficial both before and after CABG because it can reduce the progression of atherosclerosis in both native and graft vessels. Lipid therapies are recommended even for patients who have values that are in the "normal" range. The goal level for "bad" cholesterol (called LDL or low density lipoprotein) is less than 70 mg/dL (1.8 mmol/L).
- Other medications – anti-arrhythmics (digoxin) may be given on a short-term basis to prevent the development of arrhythmia, manage discomfort associated with healing incisions, or Colace to allow for regular bowel movements.
3. Cardiac Rehabilitation
Most people who have undergone bypass surgery benefit from participating in a structured, comprehensive cardiac rehabilitation program. People who participate in cardiac rehabilitation usually have appointments several times per week in a hospital or clinic, allowing the person to live and sleep at home. The potential benefits of rehabilitation include an improvement in heart function, a lowering of the heart rate at rest and during exercise, and a reduced risk of dying or developing complications from heart disease.
There are several components to cardiac rehabilitation, including exercise, reducing risk factors, and dealing with stress, anxiety, and depression. The benefits of cardiac rehabilitation are seen only when this multifactorial approach is used. In other words, one component alone is not enough.
Risk categories for exercise
Risk categories are a way of describing a person's risk of cardiovascular (heart-related) complications related to activity. Each category has a unique requirement for supervision and exercise restrictions. People in risk category A are generally healthy, do not require medical supervision during exercise, and have no limitations on the duration or intensity of exercise. Conversely, people in exercise category D have strict limits on activity and should not exercise, even with close medical supervision. Most people who have had bypass surgery are in category B or C.
- Class A – Individuals who are apparently healthy and in whom there is no evidence of increased heart-related risk with exercise.
- Class B – Individuals with established coronary heart disease that is stable. These individuals are at low risk of heart-related complications with vigorous exercise.
- Class C – Individuals who are at moderate or high risk of heart-related complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group.
- Class D – Individuals with unstable disease who should not participate in an exercise program.
Exercise Plan
The program will consider the patient's fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision.
- Type of exercise – The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, cycling, rowing, and stair climbing are some examples.
- Frequency – The recommended frequency of exercise is three to five times a week.
- Content and duration – It is important that each session consist of a 5- to 10-minute warm-up phase, a conditioning phase of at least 20 minutes, and a 5- to 10-minute cool-down phase. Eliminating the cool-down phase can increase the risk of heart-related complications.
- Intensity – One of the most important components of the exercise prescription is the intensity of exercise. This is based upon the patient's heart rate or the level of exertion. A number of formulas exist to calculate the appropriate maximum heart rate for each patient.
- Exercise progression – Over time, most people can gradually increase the level of exercise in the workout. Beneficial exercise can also be built in to the daily routine by taking a brisk walk or enjoying active play with children or grandchildren.
- Supervision – Patients who are in Class C should be in a medically supervised program where the electrocardiogram (ECG) is monitored during exercise. Advanced life support equipment (eg, a defibrillator, medications, personnel trained to use this equipment) should be on hand. This level of supervision should continue for at least 8 to 12 weeks. Lower-risk patients (Class B) benefit from a medically supervised, ECG-monitored program for the first 6 to 12 sessions. Following this, a home-based exercise program is safe and effective.
4. Reduce Cardiac Risk Factors
A number of factors increase the risk of developing or speeding the progression of heart disease. Reducing or eliminating these risk factors can be helpful, even if a person already has heart disease or has had a heart attack. Strategies to reduce risks are discussed below.
- Heart healthy diet — A heart healthy diet involves substituting veal, lean meat, poultry, seafood, whole grain pasta, lentils, corn, rice, beans, nuts, or vegetarian dishes for fatty meats, cream, cheese, and high sugar or high refined carbohydrate foods.
- Stop smoking — Cigarette smoking significantly increases the risk of coronary heart disease and heart attack. Stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half and the risk continues to decline with time. In some studies, the risk of heart attack was reduced to the rate of nonsmokers within two years of quitting smoking.
- Treat high blood pressure and high cholesterol — Medicines to control high blood pressure and high cholesterol are usually recommended after bypass surgery. (See 'Medications' above.) It is important to take these medications exactly as prescribed.
- Psychosocial treatment — Feelings of depression, anxiety, and denial are common after bypass surgery, occurring in up to 40 percent of people. Depression can reduce a person's ability to exercise, decrease energy levels, cause more fatigue, or reduce a person's quality of life and sense of well-being. Women, and in particular younger women, are at an especially high risk for depression.
- Reduce stress — Long-term stress in the home, at work, or with finances can increase the risk of heart attack, stroke, and chest pain. Many cardiac rehabilitation programs teach patients how to reduce stress in an attempt to lower these risks.
Uptodate. (n.d.). Retrieved March 25, 2021, from https://www.uptodate.com/contents/recovery-after-coronary-artery-bypass-graft-surgery-cabg-beyond-the-basics
