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Forty-eight patients who were diagnosed with triple vessel coronary heart disease
(CHD), and advised coronary artery bypass graft (CABG) surgery by their
interventional cardiologist, consulted our cardiovascular surgeon. On reviewing the
angiography, the surgeon opined that surgery could be deferred, and recommended
intense medical management, for which the patients were enrolled in the cardiac
rehabilitation program. Their risk factors were aggressively controlled both
pharmacologically and with lifestyle modification, according to international
guidelines: blood pressure (BP) below 120/80 mmHg; total cholesterol < 200 mg/dl;
triglycerides < 150 mg/dl; low-density lipoprotein (LDL) cholesterol <100 mg/dl;
high-density lipoprotein (HDL) cholesterol >40 mg/dl. Other goals included smoking
cessation, tight blood glucose control in diabetics, daily physical activity of at least
30 min, and a diet low in saturated fat and high in complex carbohydrates, fruits and
vegetables. Patients were followed-up thrice a week for an average duration of 33
sessions (~3 months). They were made to exercise under telemetry supervision for
duration of 45-60 min at an intensity of 60-80% of maximal heart rate. Their diets
were analyzed through a 3-day food recall and appropriate recommendations made,
to keep their total fat intake <30%, and saturated fat intake <7%. Their BP was
evaluated at each visit, both at rest and during exercise. Diabetics had their blood
sugar measured before and after exercise. Their anti-diabetic medications were
titrated according to their responses. Lipid profiles were measured every 3 months.
To achieve these risk reduction targets, medication changes were made in
conjunction with the patient’s cardiologist. At the time of reporting all 48 patients
were stable and had not experienced a cardiac event, including myocardial infarction
(MI) or coronary intervention. Of these, 18 patients) had completed one year from
the time of their initial angiography. With aggressive medical management and
lifestyle modification, coronary intervention can be avoided in selected cases of
patients with triple vessel CHD.
Pathology
Investigations
• Usually requires severe stenosis (>70%) with left main stem or triple vessel
disease
• No improved survival seen in patients with single or double-vessel disease
• Improved survival seen in those with poor left ventricular function
• Similar survival seen in patients undergoing angioplasty for multi-vessel
disease
Assessment of risk
• Patients at greatest risk have the most to gain from surgical intervention
• Mortality risk can be estimated using various scoring tools
• Risk is calculated by summating individual risk factors
Parsonnet score
Euroscore
Choice of conduit
Surgery
Complications
• Bleeding
• Atrial fibrillation
• Wound infection
• Poor cardiac function
• Stroke