Recommended Practices in Heart Care

If you or a loved one needs a heart procedure such as bypass surgery or an angioplasty, you want the reassurance that your hospital provides the most effective care. As we learn more about coronary artery disease, the methods used to treat it continue to improve. These improvements have led to less invasive procedures, fewer complications, faster recovery times, and better long-term results.

In the state of Washington, doctors and other health care professionals are working as a team through the Clinical Outcomes Assessment Program (COAP) to identify the best and most up-to-date methods for treating heart disease. By following research and national guidelines, the members of COAP have identified several “Recommended Practices” that are potentially linked to quality of care. These practices have been shown by scientific research to benefit patients, and they have the support of national cardiac organizations such as the American Heart Association and the American College of Cardiology. These particular practices were also selected because of the variation in the way they are used in hospitals across Washington.

COAP keeps heart specialists and hospitals informed by providing regular feedback on their use of these practices. COAP encourages all providers to use these Recommended Practices consistently whenever appropriate.

COAP is also evaluating some additional practices that appear to benefit patients; however, more information is needed about these newer, developing technologies before they can be recommended as the standard of care. COAP is gathering ongoing information on these “Evolving Technologies” to help doctors across the state determine how best to use them.

These statements are provided for your information but are not intended to replace a discussion with your own doctor when considering treatment options for coronary artery disease.

Recommended Practices

1. Using Arterial Grafts for Bypass Grafting

Coronary Artery Bypass Grafting (CABG) is a technique used to treat coronary artery disease. CABG is usually recommended for patients with disease of the left main coronary artery, or those who have blockages in several major coronary arteries, especially when the left ventricle (the part of the heart that pumps oxygenated blood to the rest of the body) is not working efficiently. CABG is also used for patients with chest pain that cannot be controlled by medication alone.

When the procedure was first developed, surgeons used a portion of the greater saphenous vein in the leg for the graft. However, better results have been found using the Left Internal Mammary Artery (LIMA), an artery within the chest wall. This artery is similar in size to the coronary arteries. It is more durable and usually stays open longer than the saphenous vein. Surgeons are finding that by using LIMA or other arterial grafts in combination with the saphenous vein, they can decrease the patient’s risk of needing repeat surgery and improve long-term survival rates.

Based on these findings, the American College of Cardiology/American Heart Association Practice Guidelines now recommends the routine use of the LIMA and/or other arterial grafts for CABG surgery. Other studies also suggest that arterial grafting requires less need for transfusions, less time spent in the hospital, and lower rates of recurring chest pain and heart attacks. Washington’s own COAP information supports these findings. On average, 86% of potentially eligible patients in Washington are receiving arterial grafts. COAP is working with hospitals and doctors in this state to consistently use arterial grafts for patients who are considered good candidates.

Certain patients, such as those undergoing emergency surgery and those who have had previous heart procedures, may not be eligible for this procedure. Treating coronary artery disease is complex and each individual case is unique. Please talk with your personal doctor if you have further questions about arterial grafting.

2. Decreasing the Amount of Time on a Ventilator

During surgery, you will be placed on a ventilator, a machine that controls your breathing while you are under anesthesia. Afterward, you may be kept on a ventilator to lessen the workload for your heart and lungs. In the past, most patients were kept on a ventilator for up to 24 hours following surgery, but more recently doctors have learned that taking people off the ventilator sooner (a process called “extubation”) has a number of added benefits.

Studies show that the longer you are on a ventilator, the greater your risks of infection and damage to your breathing passages. Shorter ventilation times have been linked with earlier mobility (getting out of bed and walking around), improved heart and lung function, lower risks of infection and savings in health care costs. For these reasons, the American College of Cardiologists (ACC) and the American Heart Association (AHA) guidelines have identified early extubation as an important part of helping patients recover from bypass surgery more quickly.

On average, about 46% of bypass patients in Washington stay on a ventilator for more than six hours after surgery. With help from the COAP program, doctors and hospitals are learning from each other about routinely taking patients off the ventilator as soon as safely possible after surgery.

Patients who have had heavy bleeding during surgery, difficulty breathing or other complications, may require longer ventilation times for safety reasons. However, for those who are doing well after surgery, removing the ventilator within several hours is generally considered safe and effective. Please talk with your doctor if you are planning to undergo a cardiac surgical procedure and have questions about the use of the ventilator.

3. Reducing the Number of Blood Transfusions

In the past, blood transfusions were given almost routinely during and after heart surgery. Because blood products (red blood cells and other parts of the blood) are often in short supply, costly, and may not always be necessary, doctors and researchers are taking a closer look at routine transfusions. Beginning with the National Institutes of Health in 1988, health care groups have created guidelines that recommend the least number of blood transfusions possible during surgery. The ACC/AHA has recommended that hospitals develop “protocols” – plans to help make the reasons for doing blood transfusions more uniform.

Despite these recommendations, the use of blood products, including red blood cells and platelets, continues to vary considerably between hospitals, both nationally and in Washington. On average, 40% of patients at hospitals in Washington will receive at least one blood transfusion as part of their bypass surgery. Some hospitals use less and others use more blood transfusions for routine care.

Washington’s doctors have been working closely with COAP to better understand practice patterns for blood transfusions. While nearly all agree that fewer transfusions are preferred, not all agree on exactly when to give them. With help from COAP, surgeons and hospitals are working together to develop consistent approaches to blood transfusions.

Patients who have active bleeding or other serious complications may need more blood products, but for those who have minimal bleeding and are doing very well during and after surgery, a blood transfusion may not be necessary. As with all medical recommendations, each case is unique, and your doctor will make judgments based on your best interest. Please talk with your doctor if you have further questions about blood transfusions in cardiac surgery.

Evolving Technologies

COAP is also following medical research on two other practices:

  • Using medications that keep the blood vessels from closing after heart procedures.
  • Performing CABG on a beating heart rather than using a heart/lung machine.

Guidelines for these practices are changing rapidly as we learn more. As part of its commitment to quality, COAP is staying abreast of these developments and working with participating hospitals to determine the best approaches to heart care. Here are the current issues surrounding these topics.

1. Using Medications that Keep Blood Vessels Open After Heart Procedures

Platelets are cells that cause blood to clot. For patients who have a Percutaneous Coronary Intervention (PCI) – a procedure to open blocked arteries, e.g., a balloon angioplasty – one risk is closure of the vessels after the procedure. This happens when platelets “aggregate” or stick together to cause a blood clot. Several anti-platelet and anti-coagulant medications have been used to reduce or prevent this problem. Giving these medications in certain combinations before the PCI appears to help keep the blood vessels open afterwards.

Based on a large amount of information, the American College of Cardiology, the American Heart Association and American College of Chest Physicians have recommended that patients who are having a PCI receive a IIb/IIIa inhibitor, heparin and clopidogrel to keep the blood vessels open. There are also several newer, developing options that researchers are studying. An option of particular interest is giving clopidogrel and bivalirudin together. This combination appears to be equally safe for patients, and easier to use for doctors. The recommendations for this group of drugs may change as more studies are done.

Through the COAP program, all hospitals in the state that perform PCI’s get up-to-date information about current use of anti-platelet drugs. COAP is carefully following the research on new technologies to understand their benefits, their possible risks, and the best ways to integrate these newer options into its quality improvement process. Talk more with your doctor to answer your questions and determine if you are a candidate for these medications.

2. Off-pump Bypass Surgery

Typically, coronary artery bypass grafting is performed on a non-beating heart. The patient is connected to an external pump called a heart/lung machine that temporarily takes over the job of the heart and lungs, putting oxygen into the blood and pumping it through the body. A special mixture of drugs is used to stop the heartbeat. After surgery, the patient is removed from the machine and the heart resumes beating on its own.

Recent advances have allowed coronary bypass surgery on a beating heart. This technique is called off-pump surgery. Off-pump surgery may have several benefits: It is less invasive, less expensive and patients who have this procedure tend to recover more quickly from surgery. Some heart centers in Washington are using this technique regularly for their CABG patients who are considered good candidates. Research by COAP doctors shows that off-pump surgery has been introduced safely into practices across the state where surgeons have had special training to learn to perform the procedure.

Because the structure of the heart varies among people, off-pump surgery may not always be the best choice for every patient. This field is rapidly changing with a number of new advances still on the horizon. As we learn more about the best ways to use off-pump surgery and other new techniques, COAP and the medical community will keep working together to make sure that patients in this state have access to the best care possible. If you are a heart surgery candidate, you may want to talk with your surgeon about the techniques currently in use at your hospital.