How Does Your Doctor Decide How to Treat Blocked Coronary Arteries?

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Donna Kimmaliardjuk, MD:

Hi, I'm Dr. Kimmaliardjuk, one of the cardiac surgeons here at Cleveland Clinic, also known as Dr. K. My specialty in cardiac surgery is really focused on coronary artery bypass grafting or CABG or bypass surgery. These are all terms you might hear, and that's a surgery that we do to treat coronary artery disease or blockages, what it's commonly referred to. So a lot of patients who come to see a surgeon for coronary artery bypass grafting commonly ask me, "Well, can't I just have stents?" And that's a great question. Whenever I'm meeting a patient with blockages or coronary artery disease, really there's three broad treatment categories or ways to approach the blockages that are found on either imaging, like a CT scan or most often a coronary angiogram or left heart catheterization.

The three broad ways to approach a blockage or treat a blockage is A) medical management, so medication, B) stenting or PCI or C) open heart surgery, coronary artery bypass grafting. Really, there's quite a few different variables that come into play to decide how we, the surgeon and the cardiologist feel or believe that would be the best way to treat those blockages. Certain things I look at are either what I would call blockage characteristics and patient characteristics and technical characteristics. So really depending on the severity or how blocked an artery is or how narrow that blockage is or tight will be kind of one of the first determining factors that kind of guides us in the decision-making of medicine versus stenting versus bypass surgery.

Also, characteristics around the blockage of how long it is, how diffuse it is. These are terms you might hear from your doctor. That will play a part in deciding how to best treat those blockages. And also how many arteries have blockages in them. Generally, the more arteries affected, the more likely that coronary artery bypass grafting is going to treat those blockages better in the long run in terms of preventing future episodes of chest pain and shortness of breath, preventing heart attacks and potentially also prolonging life.

But as I mentioned as well, there's patient characteristics that we look at. And so how are you as a patient overall in terms of other medical issues, mobility, age, your personal goals in treatment, but also for your personal life? These all come into play in deciding how we think we could best treat the blockages. And then lastly, and I think very importantly, the technical aspect is can I physically do the bypasses? There's certain instances where it's not physically or technically feasible for me to do a bypass, and so that makes decision-making a little easier because it eliminates surgery as an option.

But all in all, there's a lot of factors that the cardiologist and the surgeon are looking at when we're deciding how to best treat blockages. Most often than not, a lot of patients will start off with medications to treat blockages, and then if they're still having symptoms or heaven forbid, a heart attack or worsening of their heart function, then we look at stents versus bypass surgery. I do always like to mention that with either stents or bypass surgery, you're going to be on pretty much almost all the same heart medications after the procedure because those truly are really proven to be beneficial in preventing new blockages, stabilizing the blockages you have and helping to strengthen your heart and its heart function after the procedure.

 When there is a patient coming for open heart surgery, there are certain things that you can do at home or even in hospital before your surgery to help prepare you as best as possible to set yourself up for success afterward. One of the biggest things that I tried to encourage my patients to do is to quit smoking if they're smoking. And I know that's what every doctor has said for many, many years. And that spiel, we want to roll our eyes, but we say it because it's true. Stopping smoking is not only going to help your lungs with the immediate post-operative phase with recovery, but also help prevent new blockages from forming either in the bypasses that we do or in the arteries that we bypass. Another thing that I encourage my patients to do is to stay mobile or stay active before surgery. Of course, if you're getting chest pains or shortness of breath when you're walking and exerting yourself, I don't want you to put yourself at risk by exerting yourself heavily before surgery. But we know that patients who continue to walk and be active before surgery and come into surgery strong are going to have an easier time after surgery with recovery and getting back on their feet and their balance and their strength.

A common question I get is about what to eat or not to eat before or after surgery. This is really a bit more of a personal decision. I get a lot of questions about certain diets, for example, Mediterranean, or keto, or vegetarian, or vegan. There's no specific diet that I recommend routinely to patients because it may or may not work for you. But I try to just advocate for a well-balanced diet. So to have lots of fruits and vegetables, again, the boring stuff that your mom may have told you or your doctor. To have lean protein, lean meats, limit your red meat intake, limit your fast food intake or eliminate it all together. Try to just have a balanced diet. But if there's a certain diet that works well for you that you like, that's great, but I don't want to force you to become vegetarian or have the Mediterranean diet just because. But that too is going to help prevent new blockages from forming in those bypasses or in the arteries that we have bypassed.

After surgery a common question I get is, "When will I feel like myself again? Or when can I start doing activities that I like to do?" And so really generally the first six weeks after surgery, we want you to just be walking, no heavy exertion, no heavy lifting or any activities with your arms. And I always say it's not because of the heart, it's because of the bone. We need that breastbone to heal back together properly, and that takes about six weeks. Once that bone is healed, then you're allowed to go do any and all activities that you'd like without restrictions, which is really the beauty of bypass surgery, is that we get you back to your quality of life that you had beforehand without restrictions and without getting chest pains.

So something that I love to recommend to my patients after surgery is cardiac rehab. And this is offered all throughout the country, all throughout North America, and it's been proven to help patients get their mobility back and their strength back and get back to their normal levels of activity in a very safe and monitored way. If it's something that you're able to do or that's available to you, I absolutely recommend it. I've had great feedback from patients that they really enjoy it and it works.

At the six to eight week mark after surgery when you're starting to do rehab and increase your level of activity, you should notice that you're starting to feel more yourself. But I do like to remind patients that it may take longer than just six to eight weeks before they feel really 100% perfect. And that's okay.

Heart surgery is a big surgery, it's a big deal, and it takes a long time for your body to heal and completely recover. And that time is going to be a little different for everybody depending on them, on a lot of things and perhaps their age, how mobile they were before surgery, other medical conditions that they may have. All those things come into play. It's very common to still feel a little tired, perhaps get still short of breath at times, even at three months out after surgery or potentially longer. With time and with continuing to do walking and your rehab exercises and programs, you should notice an improvement and that you will get back to baseline. It can just take some time.

Coronary artery bypass grafting is a big surgery, yes, but it is a safe surgery. It's been shown that centers such as Cleveland Clinic that do this surgery all the time and a lot of it can do the surgery very, very safely with very high success rates and very low risk. Of course, every case and patient is unique and different, so I encourage you to talk about your risks with your surgeon. However, here at Cleveland Clinic, we do have a very low mortality rate and very excellent outcomes with bypass surgery.

Thank you so much for joining me and listening. I hope I answered some of your questions or that you were able to learn something new today. Of course, if you have questions, there are a lot of resources on our websites or any one of our surgeons would be more than happy to meet with you. So thank you again.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts, or listen at clevelandclinic.org/loveyourheartpodcast.