A 73-year-old male patient with a medical history of glaucoma, hypertension, hyperlipidemia, and a percutaneous coronary intervention of the right coronary artery in 2010 reported to his cardiologist with chest pain during exercise. His medication included aspirin 100 mg daily, valsartan/hydrochlorothiazide 80/12.5 mg daily, simvastatin 40 mg daily, latanoprost eyedrops once daily, and timolol/dorzolamide eye drops 5/20 mg/ml twice daily.
His heart rate was 55 bpm, and his blood pressure 128/70 mmHg. A physical examination and electrocardiogram showed no abnormalities, but an exercise test showed changes suggestive for ischemia. He was referred for coronary angiogram, which showed significant stenosis in the proximal left anterior descending artery, a significant stenosis distal to the stent in the right coronary artery, and no stenosis in the circumflex branch.
The heart team accepted him for coronary artery bypass grafting (CABG) (left internal thoracic artery left anterior descending, aortic saphenous vein graft right posterior descending), which was performed without complications. The day after surgery, he reported dizziness. His heart rate was 56 bpm, urine production was just sufficient (40cc/hour), and blood pressure had been low all day with systolic pressures varying between 70 and 40. No indication for bleeding was evident, and there was no significant pericardial effusion on echocardiography. After administration of saline, his symptoms, diuresis, and blood pressure improved. The episode was attributed to hypotension. He was discharged from the hospital 7 days after surgery. Medication at discharge included aspirin 100 mg daily, simvastatin 40 mg daily, pantoprazole 40 mg once daily, latanoprost eye drops once daily, and timolol/dorzolamide eye drops 5/20 mg/ml twice daily.
One month after CABG, he visited his cardiologist for follow-up. He reported feeling better every day. On examination, his heart rate was 55 bpm, and blood pressure was 160/90 mmHg. Laboratory results revealed suboptimal cholesterol levels (total cholesterol of 143.1 mg/dL, high-density lipoprotein cholesterol of 27.8 mg/dL, low-density lipoprotein cholesterol of 85.1 mg/dL, and triglycerides of 327.7 mg/dL). After adjustment of his medication, the cardiologist agreed to enroll the patient in a cardiac rehabilitation program, which he successfully finished.
The correct answer is: B. He resumed valsartan/hydrochlorothiazide.
This patient underwent CABG for stable angina. Treatment with antiplatelet therapy in addition to aspirin is not indicated in patients undergoing CABG for stable complaints. In patients who undergo CABG for acute coronary syndrome who are being treated with dual antiplatelet therapy, guidelines recommend resuming treatment with the P2Y12 inhibitor after CABG to complete 1 year of dual antiplatelet therapy after acute coronary syndrome,1,2 although evidence for this recommendation is scarce.
In this patient, it seems beneficial to improve cholesterol levels further. It is recommended to switch to high-intensity statin therapy as a first step and then add ezetimibe to maximally tolerated statin therapy before considering treatment with a PCSK9 inhibitor. In this case, the cardiologist followed that recommendation and switched to atorvastatin 40 mg once daily. Statin therapy is associated with improved vein graft patency and reduced adverse events after CABG. The effect on vein graft patency of stronger lipid-lowering therapy with PCSK9 inhibitors is currently being investigated.
Answer D could have been correct because the guidelines advise beta-blockers to be reinstated as soon as possible after CABG and to be prescribed at discharge. Beta-blockers reduce the incidence and consequences of atrial fibrillation after CABG and could have a positive effect on mortality.1 In this patient, however, this was not the preferred course of action. At discharge, no beta-blocker was prescribed due to his episode of hypotension. Moreover, he already used timolol for his glaucoma, which could have an added effect on a systemic beta-blocker, and at the check-up 1 month after CABG, he had a low heart rate. Because the cardiologist was not sure a beta-blocker would be well-tolerated, he deemed resuming the valsartan/hydrochlorothiazide more suitable in order to lower the patient's blood pressure. Lowering the blood pressure also reduces shear stress on the vein graft, potentially increasing its patency.
References
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011;58:e123-e210.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016;134:e123-55.
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:3168-209.
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