Review of Coronary
Artery Bypass Grafting

Release Date: February 1, 2014

Expiration Date: February 28, 2016

FACULTY:

Mark H. J. Litzinger, BSc, BSc Pharm, RPh
Clinical Instructor of Pharmacy Practice
School of Pharmacy, Philadelphia College of
Osteopathic Medicine–Georgia, Suwanee,
Georgia, Market Health and Wellness Director,
Walmart Stores, Inc.

Katelyn E. Horne, PharmD Candidate
Pharmacy Intern, Walmart Stores, Inc., Loma Linda
University School of Pharmacy, Loma Linda, California

Larry Rutebuka, PharmD
Pharmacy Manager, Walmart Stores, Inc.
Assistant Clinical Professor, Loma Linda
University School of Pharmacy

Joan Marie Ordonez, PharmD
Pharmacy Manager, Walmart Stores, Inc.
Ontario, California

Rahel Negash, PharmD Candidate 2014
Pharmacy Intern, Walmart Stores, Inc.
Loma Linda University School of Pharmacy

Deanna Seiler, PharmD
Senior Manager of Quality Improvement
Walmart Stores, Inc., Chicago, Illinois

Monica Litzinger, BSc, BSc Pharm, RPh
Outpatient Pharmacist Suwanee, Georgia

FACULTY DISCLOSURE STATEMENTS:

Drs. Litzinger, Rutebuka, Ordonez, and Seiler, and Mses. Horne, Negash, and Litzinger have no actual or potential conflict of interest in relation to this activity. Postgraduate Healthcare Education, LLC does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced, objective, and scientifically rigorous. Occasionally, authors may express opinions that represent their own viewpoint. Conclusions drawn by participants should be derived from objective analysis of scientific data.

ACCREDITATION STATEMENT:

Pharmacy
acpePostgraduate Healthcare Education, LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
UAN: 0430-0000-14-003-H01-P
Credits: 2.0 hours (0.20 ceu)
Type of Activity: Knowledge

FEE INFORMATION:

Payment of $6.50 required for exam to be graded.

TARGET AUDIENCE:

This accredited activity is targeted to pharmacists. Estimated time to complete this activity is 120 minutes.

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DISCLAIMER:

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities.

GOAL:

To educate the pharmacist on the epidemiology and pathophysiology of coronary artery disease (CAD) and the need for coronary artery bypass grafting (CABG). The pharmacist will learn which medications should be used as well as those that should be avoided preoperatively, perioperatively, and postoperatively.

OBJECTIVES:

After completing this activity, the participant should be able to:

  1. Understand the epidemiology and pathophysiology of CAD and the need for CABG.
  2. Recognize disease states that should be controlled and medically managed to prevent the development or further progression of CAD.
  3. Realize why the use of insulin, antihypertensives, and statins is important preoperatively as well as postoperatively for the best patient outcome.
  4. Identify when each medication should be initiated postoperatively as well as which medications should be avoided to help prevent worsening CAD, ischemic events, and death.

ABSTRACT: Coronary artery disease is a buildup of plaque in the coronary arteries that increases the risk of myocardial ischemia and myocardial infarction. As the stenosis worsens, coronary artery bypass grafting (CABG) can play a role in alleviating these risks. CABG surgery allows the blocked artery or arteries to be bypassed, increasing oxygenating blood flow to the heart once again. Many medications and lifestyle changes are indicated for CABG patients before, during, and after surgery. Pharmacists must ensure that patients are informed and that their medications are being managed appropriately to produce the most favorable outcomes, prevent further damage to the arteries, and lower the risk of angina and myocardial infarction.

In patients with coronary artery disease (CAD), the buildup of plaque in the arteries can become life-threatening. Because these arteries carry oxygenated blood to the heart, plaque can become detrimental by partially or completely blocking the arteries, preventing adequate oxygenation of the heart muscle. Narrowing of the arteries can also increase the likelihood of blood clots sticking in the artery to further block blood flow. Because the coronary arteries supply the heart, angina can occur, and the risks of myocardial ischemia or infarction greatly increase. Coronary artery bypass grafting (CABG) is a surgical procedure to restore blood flow to the heart muscle. CABG surgery can improve blood supply and oxygenation of the heart, relieve angina, reduce the risk of myocardial infarction, and improve the ability for physical activity.1

During the surgery, a cardiothoracic surgeon removes a healthy artery or vein from the patient undergoing CABG surgery and uses it to bypass the blocked portion of the coronary artery. The saphenous vein is most commonly used. This redirection of blood flow through the graft allows the heart to receive the necessary amount of oxygenation once again.2

There are different kinds of CABG surgery. Traditional CABG is an openheart surgery in which the heart is intentionally stopped using cardioplegia; the patient is then put on a heartlung bypass machine to keep his or her blood pumping.3 Off-pump CABG is similar to traditional CABG in that it is an open-heart surgery, but the patient's heart is not stopped so no heart-lung bypass machine is required.3 Lastly, there are minimally invasive, robot-directed CABG surgeries during which the chest is not completely opened. Instead, small cuts are made on the left side of the chest between the ribs to reach the heart.3 Even though there are slight variations in the types of CABG surgery, the medication related needs during the preoperative, perioperative, and postoperative periods have little variance.

Epidemiology

Based on a report from the American Heart Association (AHA), in 2008 the rate of death due to cardiovascular disease (CVD) was 244.8 per 100,000.4 Based on the mortality rate, more than 2,200 Americans die of CVD each day, which averages one death every 39 seconds.4 In 2004, CAD was responsible for an estimated 1.2 million hospital stays and was the most expensive condition treated, resulting in more than $44 billion in expenses.4 The incidence of coronary heart disease varies by ethnicity, with Native Hawaiians/Other Pacific Islanders carrying the highest risk (19.7%) and Asians carrying the lowest risk (4.9%) (FIGURE 1).4


fig1

Because of the alarming impact of CAD in the United States, CABG has become an essential tool to minimize further cardiac injury in these patients. Although the rates of CABG surgery have decreased slightly in the last decade, there were still an estimated 416,000 CABG surgeries performed in the U.S. in 2009.4 Furthermore, the in-hospital mortality rates of CABG decreased between 2002 and 2005 from 4.3 to 3.5 deaths per 100 CABG discharges, respectively.4

Pathophysiology

CAD, the number-one killer of Americans, is a chronic disease that occurs when there is a buildup of cholesterol in the arteries.5 Excess lipid deposits can lead to the hardening of the arterial wall. This process, called atherosclerosis, produces plaques that reduce the blood flow throughout the body. Inhibited blood flow and blocked arteries can result in clots that can progress into peripheral vascular disease, stroke, and heart attacks.6

There are many factors that can contribute to the narrowing of, and restricted blood flow through, the arteries, which can ultimately lead to instability of the plaque. Dyslipidemia, hypertension-related vasocon stricting hormones, hyperglycemia, adipose tissue, and proinflammatory cytokines can all contribute to blood leukocyte adhesion inside the arteries.7 These blood leukocytes “communicate” with smooth muscle cells and help elicit an inflammatory and immune response, involving leukotrienes, histamine, oxidation, matrix metalloproteinases (MMPs), and several other processes.7

With narrowing of the arterial wall, blood supply to the heart is compromised, which can lead to oxygen deprivation to the heart muscle. This can result in such signs and symptoms as chest pain, tightness, and numbness. Patients may present with myocardial infarction, stable angina, or unstable angina. CABG is one method to provide oxygenation to the heart muscle; other methods may include percutaneous coronary intervention (PCI) and medication management.6,7

Preoperative Treatment

Most patients who progress to requiring CABG have been on medical therapies to relieve angina or prevent mortality from CAD. These therapies can include medications for heart disease, hypercholesterolemia, hypertension, and diabetes. Each therapeutic category includes its own preoperative recommendations, but ultimately the risks and benefits have to be evaluated for each individual patient with a close look at the medical history. Pharmacists play a critical role in managing the disease states that may lead to CABG surgery and, through persistent medication management therapy, can positively impact those outcomes.

Prior to CABG surgery, there are several medication interventions that need to be evaluated, including medications to adjust or discontinue. Even though evaluating each category of medication is important during the preoperative state, we will focus on those that play a significant role not only during surgery, but also immediately following surgery and for long-term outcomes. CABG aims to reduce immediate and longer-term risks of myocardial infarction and death in patients with CAD.8 CABG is associated, however, with its own thrombotic risks of perioperative myocardial infarction, stroke, and pulmonary embolism. The discussion, therefore, is whether aspirin is necessary to reduce the likelihood of thrombotic events or whether its absence results in a prothrombotic state and its withdrawal is warranted in order to reduce the risk of excessive bleeding during and after surgery. Healthcare professionals offer different recommendations concerning aspirin and other anticoagulation agents, with some advising stoppage 3 to 5 days prior to surgery and others stating it is better to end aspirin therapy within 7 to 10 days of surgery. The different schools of thought on aspirin can be seen not only among different cardiac surgeons and cardiac surgical institutions, but in the guidelines they follow. The Society of Thoracic Surgeons' (STS) Class IIa recommendation advises stopping aspirin 3 to 5 days before elective CABG while recommending continuation of aspirin for high-risk CABG surgeries. For those not on aspirin, the STS recommends starting aspirin prior to elective or urgent CABG.9 The most recent American College of Cardiology Foundation (ACCF)/AHA guidelines recommend preoperatively administering 100 mg to 325 mg of aspirin daily, even though their previous recommendation was to stop aspirin 7 to 10 days before CABG.10

Even though aspirin is the most widely discussed preoperative medication for CABG, the ACCF/AHA also recommends various other therapies. Adenosine diphosphate receptor inhibitors should be stopped at least 5 days for clopidogrel and ticagrelor (level of evidence B) and 7 days for prasugrel (level of evidence C) before surgery to limit the need for blood transfusions. For those patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding complications. Short-acting glycoprotein (GP) IIb/IIIa inhibitors (IV use only) should be discontinued for at least 2 to 4 hours before surgery, with abciximab in particular being discontinued for at least 12 hours (level of evidence B). STS Class IIb preoperative antiplatelet therapy for patients referred for urgent CABG may require surgery to occur within 5 days of discontinuation of clopidogrel and ticagrelor and within 7 days for prasugrel (level of evidence C).10

Since plaque buildup is associated with the need for CABG surgery, one could reason through the benefits of lipid-lowering therapy. The use of lipid-lowering medications prior to surgery has been linked with a decreased risk of death after CABG.11 The use of statins in particular has been associated with decreased perioperative complications and even improved outcomes post CABG. Several studies show that progression to atherosclerosis in bypass grafts is significantly reduced. Preoperative statin use can also help reduce progression to native artery disease following surgery.11 The ACCF/ AHA guidelines recommend continuation of a statin if a patient is already taking one or addition of a statin for patients not currently on one. Discontinuation of a statin or any other dyslipidemic therapy is not recommended before CABG in patients without adverse reactions to therapy.10

Antihypertensive medications help maintain adequate blood flow and reduce the stress load of the heart. Their utilization can be seen preoperatively, perioperatively, and postoperatively. Prior to the 2011 ACCF/AHA guidelines there was little evidence to support the use of beta-blockers routinely after CABG, but their use preoperatively is often seen in patients requiring CABG who have a history of myocardial infarction and congestive heart failure.12 The reduction in cardiovascular events in patients with CAD afforded by ACE inhibitors (ACEIs) would make one conclude that their use would be beneficial in CABG. Their antiatherosclerotic, antithrombotic, and anti-inflammatory properties—along with their ability to lower blood pressure—would all seem necessary in CABG patients. However, the use of ACEIs is controversial owing to the theory that their preoperative use leads to the lowering of systemic vascular resistance in the early postoperative phase, resulting in hypotension and renal dysfunction. Preoperative ACEI use is associated with worse early clinical outcomes in patients undergoing CABG.13 There is a school of thought that stopping ACEIs prior to CABG and restarting them after surgery might be a reasonable way to maximize their cardioprotective benefits while limiting the impact of their negative outcomes.

Patients with diabetes have worse outcomes after CABG compared to nondiabetic patients, especially insulin-dependent patients.14 This is simply due to the link between diabetes and cardiovascular disease. Patients with type 2 diabetes undergoing insulin treatment are already immune-compromised and have overall poor health in comparison to nondiabetic patients. They most likely also have other chronic heart disease risk factors and therefore are at higher risk for poor outcomes after CABG. It is important to aggressively manage the patient’s pre- and post-CABG blood glucose levels to improve outcomes.

Treatment and Monitoring

During CABG Surgery To reduce the patient’s pain, thereby increasing comfort, during CABG, the use of general anesthetic and volatile anesthetic-based regimens are STS Class I and Class IIa recommendations, respectively.5 General anesthetics may include ketamine 2 mg/kg or propofol 0.5 mg, along with sevoflurane, fentanyl, midazolam, rocuronium, and vecuronium (TABLES 1 and 2).15-19


tbl1


tbl2

Although its effectiveness is uncertain intraoperatively, the use of continuous IV insulin (targeted to maintain blood glucose levels below 140 mg/dL) is an STS Class IIb/Level B recommendation.10 Continuous IV insulin is administered early postoperatively to prevent hypoglycemia, adverse effects, and deep sternal wound infection after CABG (glucose target is less than or equal to 180 mg/dL).10 Perioperative/prophylactic use of various antibiotics is recommended to prevent infection, along with a Class IIa/Level A recommendation for the use of intranasal mupirocin in nasal carriers of Staphyloccocus aureus.10

Overall blood conservation is a must in order to prevent hemodilutional anemia and allogenic red blood cell transfusion (Class I/Level B).10 In patients using on-pump CABG, the use of lysine analogues is a Class I/Level A recommendation, intraoperatively and postoperatively, to promote blood conservation.5 When necessity demands a blood transfusion, leukocyte-filtered blood is useful in the prevention of perioperative infection and in-hospital death (Class IIa/Level B).10 More extensive preand postoperative treatment may be observed for those patients requiring CABG surgery.

There is a Class IIa/Level B recommendation for the use of continuous electrocardiogram monitoring to detect ischemia, as well continuous ST-segment monitoring for detection of ischemia in the intraoperative period.10 Pulmonary artery catheterization is even more highly recommended on a Class I/Level C, IIa and IIb/Level B scale, before anesthesia or surgical incision, intraoperatively, or early postoperatively for those patients with acute hemodynamic instability, and is generally performed once taking into account baseline patient risk.10 Although the effectiveness of using electrocardiogram and near infrared spectroscopy to detect cerebral hypoperfusion and oxygen saturation is uncertain, a Class IIb/Level B recommendation for monitoring of the central nervous system still stands.10 A transesophageal echocardiography, which is a Class I and Class IIa/Level B recommendation, is indicated for the evaluation of potentially life-threatening hemodynamic disturbances while also monitoring ventricular function, regional wall motion, and valvular function.10

Postoperative Treatment

Care for patients who have undergone CABG is important in order to prevent postsurgical complications. Patients need to reduce risk factors that can increase the risk of myocardial infarction and myocardial ischemia.20 Lifestyle changes such as diet, exercise, and smoking cessation can help reduce these complications. Medications such as antiplatelet therapy, beta-blockers, statins, and ACEIs can help lower these risks further (TABLE 3).10,17,20,21


tbl3

Antiplatelet therapy should be started soon after CABG. If patients did not receive aspirin before surgery and they do not have any contraindication to this medication, aspirin 100 to 325 mg should be initiated within 6 hours after CABG and continued indefinitely.10,21 If patients are allergic to aspirin or they have a contraindication to the medication, then clopidogrel 75 mg daily should be given.10,21 Many healthcare providers prescribe clopidogrel along with aspirin for long-term use in patients who have undergone CABG. The 2011 ACCF/AHA guidelines do not have a recommendation for or against the long-term use of clopidogrel.10

Beta-blockers are often used to manage patients who have had bypass surgery. They function by blocking beta1 receptors. Blockage of these receptors helps reduce heart rate, myocardial contractility, and blood pressure. This in turn helps reduce the stress on the heart, resulting in improved ventricular filling and coronary perfusion.10 Beta-blockers also help prevent postsurgical complications such as atrial arrhythmias and reinfarction.10 Patients who are going home after bypass surgery should be given beta-blockers, which should be taken as prescribed by their clinicians.21

Statins are important part of the medication regimen in patients who have undergone CABG. They lower cholesterol, thus preventing occlusion of blood vessels. Statins also have secondary effects such as improving endothelial function and decreasing inflammation in the arteries.10 The ACCF/AHA guidelines recommend that statin therapy be continued after CABG in order to continue to lower the LDL cholesterol to less than 70 mg/dL.10,20,21 Statins also decrease the risk of death in patients with CAD.10,20,21

ACEIs are given post-CABG to patients who are clinically stable and do not have contraindications to the drug. ACEIs block the renin-angiotensin-aldoste rone (RAS) system, and it is believed that during and after cardiopulmonary bypass, the RAS is hyperactive and causes microvascular injury.21 By blocking this system, ACEIs may have the potential benefit of not only lowering the patient’s blood pressure but also decreasing the risk of an ischemic event.10,21 ACEIs should be given to all patients post-CABG to prevent reinfarction and to decrease mortality.21

Lifestyle Modifications After Surgery

The first lifestyle modification recommended for patients is to quit smoking. Smoking can decrease the oxygen supply to the heart, damage the artery walls, and increase heart rate and pressure. When the patient is ready to quit, pharmacists can provide information and encouragement to help the patient in his or her journey. Pharmacists can urge patients to get support from their family and friends as well as their doctor. Patients may be unaware that there are prescription medications available to help with smoking cessation. Many hospitals have smoking-cessation services, so patients can be encouraged to seek out those resources. Pharmacists can also help the patient select an appropriate nicotine-replacement product based on the patient's smoking history.22

The next big issue facing post-CABG patients is effective blood pressure control. Hypertension adds stress to the heart and speeds the process of atherosclerosis. Many patients will be on antihypertensive medications, and it is important to explain the necessity of medication adherence. Patients should take their medication as prescribed and continue to do so unless directed by a physician. Even if patients have adverse effects, they should discuss alternative measures with their physician before discontinuing without notice. Blood pressure should be checked at least every 6 months, and scheduled visits to the physician's office should be kept to ensure that blood pressure is being adequately controlled. Patients should be encouraged to follow a low-salt diet and avoid adding excess salt to foods. Regular exercise and weight loss should be encouraged in overweight patients. Patients will be at different stages of physical ability, so instead of encouraging specific exercise regimens, pharmacists should encourage patients to speak with their physician about a regimen fit for their level of rehabilitation.22

Lowering cholesterol is another issue for patients after bypass surgery. While medications will likely be utilized, patients can also modify their diet to aid the process. Diets should be low in saturated fat, trans fat, and omega-6 polyunsaturated fats. These are found in partially hydrogenated vegetable, corn, safflower, sun flower, and tropical oils as well as in dairy fat. Diets should have higher amounts of monounsaturated fats, which can be found in fish, flaxseed, canola oil, soybeans, and some nuts. Foods that contain plant stanols or sterols can lower LDL cholesterol; these are included in some margarines and juices. Overall, patients should adopt a diet high in vegetables, whole fruits, and whole grains to provide necessary vitamins and minerals and avoid empty calories.22

Diabetes is another risk factor for further artery damage. Pharmacists should explain to patients the importance of controlling their blood glucose. Control ling blood sugar can also promote wound healing and help prevent infection. This can be done partly through diet and exercise regimens, but medications can also play a large role. It is important that patients check their blood glucose as recommended by their physician. Medication adherence is also important to ensure that physicians can manage the diabetes most effectively. Pharmacists can play a significant part in patient edu cation when it comes to injectable medications for diabetes. If patients are not using their medications properly, the results will not be ideal.22

Another lifestyle modification is decreasing stress. There are many relaxation techniques that patients can seek out, and each patient will be different in this regard. Patients with jobs that are especially demanding physically may need to start back slowly, or find a position that is less physically draining.22

The Role of the Pharmacist

Pharmacists have always played a key role in improving patient morbidity and mortality, patient outcomes, and overall quality of life. Under Senate Bill (SB) 493 in Califorina, pharmacists would be provided the ability to practice their varied expertise, including medication management and disease-state monitoring. With SB 493, a qualified California pharmacist's scope of practice may allow him or her to "furnish self-administered hormonal contraceptives, nicotine replacement products, and prescription medications not requiring a diagnosis that are recommended for international travelers, as specified. Additionally, the bill would authorize pharmacists to order and interpret tests for the purpose of monitoring and managing the efficacy and toxicity of drug therapies, and to independently initiate and administer routine vaccinations, as specified."23

Pharmacists are the most accessible healthcare professionals and are equipped with essential knowledge that the public, including postoperative CABG patients, require. Monitoring, managing, and prevention are at the forefront of healthcare, and these are areas where the pharmacist can step in. Informed pharmacists will be able to detect incomplete therapeutic regimens and provide information to help tailor regimens to specific patient populations. Pharmacists can also emphasize the extreme importance of medication adherence to patients both preand postoperatively. In addition to medicationrelated needs, pharmacists can provide information on the lifestyle modifications as discussed above.

Conclusion

There are many medications indicated before, during, and after CABG surgery. In addition to medication reconciliation strategies, postoperative patient healthcare management can be extremely beneficial.20 To reduce the risk of continual complications and worsened heart disease, strategies must be introduced to patients and/ or their family/loved ones.20 Efforts to ensure smoking cessation, control high blood pressure, improve choles terol levels, begin exercising regularly, and reduce stress are crucial.20 Some of these changes can be made by adjusting lifestyle habits through diet, exercise, smoking cessation, stress relief, etc.20 However, lifestyle changes alone may not be adequate, and medications are often needed. Pharmacists can play an integral part in the medicinal and varied therapeutic management of patients who undergo CABG surgery.20

REFERENCES

  1. Cardiac procedures and surgeries. American Heart Association. www.heart.org/HEARTORG/Conditions/HeartAttack/PreventionTreatmentofHeartAttack/Cardiac Procedures-and-Surgeries_UCM_303939_Article.jsp. Accessed September 16, 2013.
  2. What is coronary artery bypass grafting? National Institutes of Health. www.nhlbi.nih.gov/health/health-topics/topics/cabg/. Accessed September 16, 2013.
  3. Types of coronary artery bypass grafting. National Institutes of Health. www.nhlbi.nih.gov/health/health-topics/topics/cabg/types.html. Accessed September 16, 2013.
  4. Roger VL, Go, AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012:e2-e220.
  5. Coronary artery disease: causes, symptoms, treatments. WebMD. www.webmd.com/heart-disease/guide/heart-disease-coronary-artery-disease. Accessed October 10. 2013.
  6. Atherosclerosis: causes, symptoms, tests, and treatment. WebMD. www.webmd.com/heart-disease/what-is-atherosclerosis. Accessed October 10, 2013.
  7. Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation. 2005;111:3481-3488. http://circ.ahajournals.org/content/111/25/3481. Accessed October 10, 2013.
  8. Myles PS. Stopping aspirin before coronary artery surgery: between the devil and the deep blue sea [editorial]. Circulation. 2011:123:571-573.
  9. Ferraris VA, Ferraris SP, Moliterno DJ, et al. The Society of Thoracic Surgeons practice guidelines series: aspirin and other antiplatelet agents during operative coro nary revascularization (executive summary). Ann Thorac Surg. 2005;79:1454-1461.
  10. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. American Heart Association. https://circ.ahajournals.org/content/124/23/e652.full. Accessed September 19, 2013.
  11. Powell BD, Bybee KA, Valeti U, et al. Influence of preoperative lipid-lowering therapy on postoperative outcome in patients undergoing coronary artery bypass grafting. Am J Cardiol. 2007;99:785-789.
  12. Okrainec K, Platt R, Pilote L, et al. Cardiac medical therapy in patients after undergoing coronary artery bypass graft surgery. J Am College Cardiol. 2005;45(2):177-184.
  13. Miceli A, Capoun R, Fino C, et al. Effects of angiotensin-converting enzyme inhibitor therapy on clinical outcome in patients undergoing coronary artery bypass grafting. J Am College Cardiol. 2009;54(19):1778-1784.
  14. Deaton TV. Patients with type 2 diabetes undergoing coronary artery bypass graft surgery: predictors of outcomes. European J Cardiovasc Nurs. 2009(8):48-56.
  15. Lexi-Comp, Inc. (Lexi-Drugs). www.lexi.com. Accessed April 15, 2013.
  16. Clinical Pharmacology. Tampa, FL: Gold Standard, Inc. www.clinicalpharmacology.com.
  17. Micromedex Healthcare Series. www.micromedix.com. Greenwood Village, CO: Thomson Healthcare.
  18. Basagan-Mogo E, Goren S, Korfali G, et al. Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine. Clinics. 2010(65.2):133-138.
  19. Newman MF. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. New Engl J Med. 2001(344):395-402.
  20. Aroesty JM. Patient information: recovery after coronary artery bypass graft surgery (CABG) (beyond the basics). Uptodate.com. www.uptodate.com/contents/coronary-artery-bypass-graft-surgery-beyond-the-basics. Accessed August 8, 2013.
  21. Aranki S, Aroesty JM. Medical therapy to prevent complications after coronary artery bypass graft surgery. Uptodate.com. www.uptodate.com/contents/medical-therapy-to-prevent-complications-after-coronary-artery-bypass-graft-surgery. Accessed August 8, 2013.
  22. University of Michigan Cardiovascular Center. Heart Surgery Information for Patients and Their Families. Ann Arbor, MI: University of Michigan Cardiovascular Center; 2007.
  23. U.S. Senate. California Legislative Information. Senate Bill 493. Sen. Ed Her nandez. Legislative Counsel Digest. http://leginfo.legislature.ca.gov/faces/billTextCli ent.xhtml?bill_id=201320140SB493. Accessed December 7, 2013.

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