???? ??? ??(CABG) ??? ????

1
???? ??? ??(CABG) ??? ????

• ? ? ?
• ??? ????? ????
• ????????

2
CABG ??? ??

• Indication (ACC/AHA Guideline)
• Main LCA disease (50 ??) or TVD
• Advanced stage of CAD
• The highest risk group of CAD

3
CABG? ???(??)??? ? ?????

• ????? ??? ??? ????? ??? ? ??. ??? CABG? ?? ?? ???
  ??(gt70)?? bypass??.
• ?????? ??? infarct related artery? ??(? 25)??
  50??? ??? ???.
• mild stenosis can rupture, thrombose,
  and occlude causing myocardial
• infarction or sudden death Eugene
  Braunwald 1998
• CABG? ?? ???? ??? ????? ???. Bypass? ? ???
  ???????? ????.

4
?????? ??? ????

• Aspirin? ?????(Clopidogrel, Cilostazol)
• Nitrate? symptomatic relief? ???, endothelial
  function? ??,
• ??? ????? ???? ?????? ??? ??(RCT?? ??).
  
• Beta???(????, ???? ??, ?????, ???? ??)
• ACE ???? ARB(????, ????, ????? ? ??)
• CCB(????, Anti-ischemic effects, ??????, ??????
  ??)
• Statins(?? ?? ???? ??)

Sudden Deaths in Beta-blocker Trials
5
CABG? ????? ???(mayo clinic)Circulation Feb 2006
Aspirin? CABG 5???? ??? ?(1,316?)? ???? ??
?(320?)? ??
6
Atrial Fibrillation(AF) after CABG(1)

• Incidence is about 30, Ventricular Rate is
  usually over 100/min
• AF increases mobidity (MI, CHF, Stroke) and
  mortality, prolong ICU Study
• For AF over 48hrs, anticoagulation is recommended
  
• Treatment
• For rate control(60/min), oral or IV beta blocker
  is the best choice
• Digoxin is less effective
• CCB (diltiazem, verapamil) can be used
• For conversion to sinus rhythm, amiodarone (IV or
  oral), flecainide, propafenone can be effective.

7
AF after CABG(2)Prophylaxis Beta blocker
and/or Amiodarone
Risk Assessment for Atrial Fibrillation, Post-CABG

• Recommendation Pre-op Beta blocker and/or
  Amiodarone
• Atenolol 50mg q.d or b.i.d
• Betaxolol 10-20mg q.d
• Amiodarone, IV or oral

8
CABG??? ???? ??(1)

• ???? ??????(IHD)? 4? ???? ??.
• JNC 7 ???? 120/80mmHg, ??? 140/90 ??
• WHO/ISH ???? 120-129/80-84mmHg??? 140/90
  ??
• DM target 130/85 IHD ? Target

9
CABG ??? ???? ??(2)
???????(DCM)? ?? ???? DBP? ???? ??? J Curve? ????
???.
IHD???? DBP? 85mmHg??? ? ???? ????? J Curve??? ??
?? ? ? ??.
10
CABG???? ?????? ???
Beta-blockers are most neglected drugs in IHD
Table. Mortality in Long-term Beta-blocker Trials
11
??????(IHD) ???? statin? ???

• National Cholesterol Education Program (ACEP)
• ATP? Guidelines
• LDL Cholesterol 100mg ?? ?? ??? 70mg??? ???
• ?? ?? ?? CABG??? Stain? ???? ??.

12
The Role of ACE Inhibitor for IHD(1)
??? ?? ??? ????? ACEI? IHD? ??? ??? ? ??(HOPE
Study)
13
The Role of ACE Inhibitor for IHD(2) Hope
Extended Study (Circulation Oct 2005)
MI? ???
Stroke? ???
14
The Role of ACE Inhibitor for IHD(3) Hope
Extended Study (Circulation Oct 2005)
15
CABG?? ??? ????? ??

• CABG? ??? ??? ????? ???. ??? ??? ????? ???
• ??? ?????. ???????(LVEF lt40??)? ?? ??? CABG?
• ? ?? Beta-blocker, ACE??? ?? ARB, Aldosterone
  antagonists? ????
• ??.
• ???(Lasix)
• Beta-blocker(cavedilol, metoprolol, bisoprolol)
• ACE Inhibitor(captopril, enalapril, ramipril,
  perindopril, lisinopril etc.)
• ARB (losartan, valsartan, lrbesartan,
  olmesartan, telmisartan, eprosartan)
• Aldosterone Antagonists(Aldactone)

16
CABG ??? ????

• ? ?
• Graft? native vessel? ??? ???? ?? aspirin? ???
  ???
• (clopidogrel, cilostazol)? ???? ??.
• SBP(120-130mmHg)? heart rate(50-60/min)? ????
  ???? ??.
• ??????? ??? ??? ?? ?????? ???? ??.
• ?? ?? ???? ACE??? ?? ARB? Statin? ???? ??(??? ??
  ????? ?????).
• ????? ??? ??? ??? ?? calcium ????? ????.
• ???????? ?? ? ACEI, ARB? spironolactone? ???? ??.
  
• ??? ??? ?? ????? ???? ??? ??? ????.