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Indications for a coronary artery bypass graft are life-threatening ischemic heart disease, or intractible angina. Although the CABG surgery has many benefits for the patient, it also has a high in-hospital mortality rate. Also the CABG surgery only has an 80% immediate symptomatic improvement.
There are many medical conditions that can effect the outcome of a CABG. These factors increase the risk of hospital readmission within two years of the surgery. It should be noted that post-op hospital readmission plays an important role in morbidity. Also the outcome plays a large role in patient well being and healthcare financing. The patient and the medical care system can be helped by identifying these medical conditions and giving the patient preventative care.
These pre-existing medical predictors of outcome include angina pectoris, chest pain (unidentified cause), heart failure, arrhythmia, stroke, diabetes, renal disease, and COPD. Other factors that can cause readmission or poor outcomes are neurological complications, complications to primary surgery, acute MI, post-thoracotomic syndrome, infection, and other surgical diseases.
COPD has been shown to be a significant risk factor for early and midterm morbidity and mortality in patients receiving a CABG. These patients have been shown to have longer hospital stays and have a lower quality of life after a CABG. COPD patients also have a higher incidence of having a phrenic nerve injury (PNI) along with their CABG. A phrenic nerve injury alone has been shown to increase morbidity and mortality. Patients with COPD have a 43% chance of having a phrenic nerve injury during a CABG. Patients with COPD and PNI have about a 75% chance of a reversal of their PNI, this generally takes around 19 months.
Postoperative outcomes varied between those patients with COPD and PNI (group 1) and those without COPD or PNI (group 2). Group 1 patients had a hospital stay around 6 days longer than group 2 patients. Group 1 also stayed in the ICU about 2 days longer and had to be reintubated about 38% more than group 2. Group 1 patients had a 62% chance of being intubated over 24 hours than did group 2 patients. Group 1 also had a 28% greater incidence of postop pneumonia than group 2. Group 1 had bronchospasm requiring intravenous treatment about 52% more than group 2 patients did. Most important was that mortality is 40% more in group 1 than in group 2 after 45 months. It should be noted that patients with an FEV1 of less than 1.25 had an increased rate of acute mortality after their CABG.
Another way to assess patient outcome is through patient’s perceptions of changes in their state of health and how it effects their lives. This is also known as quality of life and is assessed by how the patient perceives and reacts to their lives (i.e., interaction with friends and family, or their occupation.) Psychological dysfunction is common following a CABG and can persist in the late postoperative period. Incidence of dysfunction ranges from 33 to 83 percent in the early postop period, and persists over one year in 35% of patients. Also, the risk of postoperative psychological dysfunction increases with age.
For many patients, cardiac surgery is seen as a life threatening procedure. Failure to adapt to the procedure leads to an increase in anxiety and depression in 25% of patients. This creates a need to evaluate the patient’s perceptions of the procedure to understand the effects of this perception on recovery. Identifying these perceptions before surgery can help in the decision of how to mentally treat the patient and improve outcomes. Patients with high pre-surgery levels of anxiety and depression show high levels of anxiety and depression postoperatively. Esteem support shows to be the most important factor related to feelings of well-being and long term recovery. Another factor that has shown benefit with coping is when the patient feels in control of their care.
