BACK TO WORK

hari ni baru start kerja semula, patut smlm tapi stomach upset lak, hari ni dah k sikit so try to be at the office today after almost 2.5 months MC due to CABG.
Hope can get back the rhythm and as usual..

Nothing much today, work progress slow due to several factors such as rainy season, year end and so on.

MY APPT NEXT WEEK - 2ND WEEK NOV 2015

Appointment and follow up next week are as below:

1. 9/11/2015 - physiotherapy lecture, Penang GH
2. 11/11/2015 - 4th follow up with cardiologist , Penang GH
3. 11/11/2015 & 13/11/2015 - physio at Metro specialist centre

InshaaALLAH should be able to work by 16/11/2015

PHYSIOTHERAPY @ METRO SPCL CENTRE

Start my physio di Metro Spcl Centre pada 4/11/2015, selang sari selama satu bulan untuk pemulihan cardio selepas operasi.  Harap lebih baik lepas ni dan inshaALLAH akan bekerja semual tengah bukan November ni dan selepas follow up pada 11/11/2015 ini.

Alhamdulillah wounds semua dah kering dan k dalam masa 2 bulan, tinggal sedikit ngilu di dada jer lagi..

lps ni kena jaga senaman, food, sleep, stress level dan my medication...

MY FOLLOW UP - 28/10/2015

Follow up di Penang Cardiothorasic clinic , outcome seperti di bawah:

• luka semua dah k
• mungkin boleh kerja dah . 1/12/2015
• exercise will start 2/11/15 for 6 weeks straight then assessment by theraphist.
• next follow up 11/11/15
• driving, sports and other activities will take place btw 4 to 6 months..
• will transfer hospital to Metro 

16.10.2015

nothing much to day, just relax in the house....reading and with my net......
went out to Tesco just now, snow wash car, lunch there and buy groceries.

POST CABG - progress

Tunggu luka sikit di tangan dan kaki baik jer , lepas tu exercise program before i can get back to work...inshaALLAH..

MY WORK ACCORDING TO PRIORITY

My work according to priority are as below 

STAGE 1

TOP 

• TNB perma supply

MEDIUM

• O&M manual
• punch list 

LOW

• Toilet - sanitary & plumbing, C&S internal/external

STAGE 2

• still long way to go, easily another year
• involving Emergency draw down, VH1 and crest works (2 x compact sub and street lights)
• to check and look at shop drawings for Mecky and Electrical once i come back...

Note:

INSHA'ALLAH this is what i am going to do once i am back to normal and healthy after my post CABG..

POST CABG - MY EXERCISE

PHYSICAL ACTIVITY -

IMPORTANT POINTS TO REMEMBER

When you first go home, you will be looking at finding a balance between rest and activity.

“The time it takes to return to a normal activity level will vary greatly, depending on your

age, your individual energy level and your previous state of health and fitness”1. The activity

guideline in this section will progress at a pace that gives your heart time to heal after your

open-heart surgery. For the best health benefits you should exercise regularly throughout

your life.

***In the first 6 weeks after your surgery it is recommended that you try to conserve

energy, as you may tire easily.

1. TIPS FOR SAVING ENERGY – Remember, all “on your feet activity” is work for your

heart. REST and ACTIVITY periods should be well BALANCED and spaced throughout the

day. However, a day working in your house or garden DOES NOT substitute for your

cardiac walks.

·  Remember getting dressed in the morning, eating regular balanced meals

and your walking program are your top priorities.

·  Allow plenty of time to complete your task; pace yourself and DO NOT RUSH.

·  Alternate heavy and light tasks throughout the day.

·  Be sure to take adequate periods of rest during whatever activity you do. Do not try

to do more in a day than your body tells you can. Avoid extended sleep periods

during the day, although short naps are okay.

2. STAIRS AND HILLS – It requires more energy to climb stairs or hills than walking on

the level – take your time and rest when you need to.

·  You should be able to carry on a conversation when going uphill. Slow

down and rest if talking becomes difficult.

·  When you first go home plan your day so that you do not have to climb stairs

unnecessarily. Choose walking routes that are not hilly for the first 6 weeks.

·  Gradually incorporate “ hilly challenges” into your program as your strength and

endurance improves.

·  Avoid uneven ground and beach walking until your balance and endurance improves

(4 – 6 weeks).

3. EATING AND DRINKING

·  Exercising immediately before a meal may interfere with your appetite.

·  Wait 1-2 hours after a large meal before exercising.

·  It is okay to walk slowly after a snack.

·  Avoid coffee and alcohol prior to exercising. The caffeine in the coffee is a stimulant

and may affect your exercise ability. Studies have shown that alcohol intake slows the

flow of blood through the heart arteries.

·  Ensure you keep hydrated. Try to drink fluid every 20 minutes during your exercise.

1 Stanford Hospital & clinics “After your heart surgery - patient handbook”

Page 4 of 18 Vancouver Island Health Authority

General Guidelines for Home Activity and Exercise after Coronary Artery Bypass or Valve Surgery

Cardiac Rehabilitation Program

4. WEATHER & OTHER RELATED CONSIDERATIONS

·  Both hot and cold weather and windy conditions may raise your heart rate and make

you tire more easily. Be sure to slow down your pace and dress appropriately.

·  In cold weather exercise during the warmest part of the day, wear a scarf around your

mouth and nose to warm the air before it reaches your lungs.

·  On hot days exercise during the coolest part of the day.

·  During extreme weather conditions you may find it easier to walk in a mall or use a

stationery bike (with no resistance).

·  Avoid saunas, extremely hot or cold showers, jacuzzis and hot tubs until ok’d with

your doctor.

5. PROTECTING YOUR STERNUM (BREAST BONE) – Your breastbone takes 8 – 12

weeks to heal.

·  Avoid lifting, pushing and pulling more than 5 – 10 pounds, such as lifting groceries,

small children, pets, etc.

·  A shower chair and handheld showerhead, which can be borrowed from the Red

Cross, will make it easier to shower without stressing the sternum.

·  Avoid using only one arm and activities reaching behind your back.

·  Heavy lifting, pushing, pulling and sustained arm activities above shoulder level place

extra stress on your heart and sternum (such as vacuuming).

·  Avoid vigorous sports / activities for 3 months, such as golfing, tennis, swimming.

Check with you doctor before resuming.

·  Take frequent rest breaks with any arm activities.

6. Avoid sitting for longer than 1 – 1 ½ hours e.g., long distance traveling, T.V., computers.

Get up and walk around to help the circulation in your legs, and to avoid blood clots.

7. Heavy straining or breathing-holding (i.e. bowel movements) can cause a great strain on

the heart. Use stool softeners or laxatives if necessary to prevent constipation.

8. Avoid exercising when you are angry or upset. Watch that you do not compete with

anyone including yourself.

9. It is important to continue your incentive spirometer and breathing exercises until you

have reached your pre-operative level.

This are some of my exercise program before i can do my normal activities back..

INTERPOLATIONS MADE TO THE QURAN

Something to ponder and very crucial..

LIST OF INTERPOLATIONS MADE TO THE QURAN

1. Saying that the Quran being is not self-sufficient and that there is need for additional speculations.
2. Taking the hadiths as a source for Islam.
3. Sectarian scholars pronouncing fatwas or ijtihads (canonical jurisprudence).
4. Practices conforming to sectarian dictates.
5. Equating sects with the religion.
6. Reciting the Quran for the sake of its music without understanding the text.
7. Using the Quran as a book of prayer recited for the souls of the departed.
8. Contributing authority to the Prophet outside the scope of the Quran.
9. The fact that God created everything for the sake of Muhammad.
10. Competition between prophets. Supremacy of some prophets over other prophets.
11. Imitation of the ways and manners of the Prophet.
12. The belief that the Quran has missing points which can be found in other books.
13. To announce certain select devotees to be Muslim saints and visit their tombs with all sorts of reverential rituals.
14. To idolize the sheikhs of religious orders.
15. Establishing a type of communication with the sheikhs by a special ritual called Rabyta.
16. To claim that only the Sunnites or the Shiites are to go to paradise.
17. To declare the Jews and Christians as the future dwellers of hell.
18. To adopt Arabic customs and traditions as religious practices.
19. To come forth alleging to be reformist with a view to changing the Quranic religion.
20. To formulate religious precepts ascribing them to the Prophet.
21. To claim that the vote of the majority always prevails.
22. To interpret the continuity of sects as evidence of their genuineness.
23. A canon book called Majalla/Mecelle.
24. To deny reason and favor apishness.
25. Hostility against science.
26. Hostility against the arts.
27. To abide by the rules that the book entitled Sahihi Bukhari lays down.
28. To abide by the rules of the hadith book entitled Muslim
29. To abide by the rules of the hadith books Kutub-i Sitte or other such books.
30. To venerate individuals to whom religiosity is ascribed other than the Prophet.
31. The allegation that all of those who had the privilege to set eyes on the Prophet (sahaba) were on the right path.
32. The wearing of the headscarf.
33. The wearing of the veil.
34. Segregation of men and women.
35. The fact that a woman is not allowed to travel alone.
36. The wrong and absurd belief that a woman can never repay the debts she owes to her husband even if she were to lick him from head to foot when he is in a deplorable state covered with pus.
37. “If prostration was permitted to any entity other that God, the wife should prostrate herself before her husband” claimed the hadith.
38. That a woman cannot become a head of state or an administrator.
39. That women have no right to vote for the governing body of the government.
40. That women’s voices must not be audible to men.
41. That women are not allowed to perform the Friday salat.
42. That women is not allowed to perform salat, fast, recite the Quranor enter a mosque during their period.
43. Covering women with all sorts of outer garments.
44. That it is forbidden for women to shake hands with men.
45. That a man is not allowed to sit in a chair previously occupied by a woman whose warmth is still preserved.
46. That a woman cannot stay in an enclosed space where there are men.
47. That women are considered along with dogs and pigs to invalidate the salat of a praying man.
48. That the majority of women are doomed to go to hell.
49. That women are evil by nature.
50. That women lack intelligence.
51. That women must be kept indoors.
52. That women is forbidden to wear perfume.
53. That women are not allowed to use makeup.
54. That a wife must obey her husband as a slave does.
55. That a woman is required to have sexual relations whenever her husband calls her.
56. That two female witnesses equal one male witness.
57. That a woman must have her parents permission in order to get married.
Stoning to death of the adulterer.
58. That the papyrus on which the verse regarding stoning the adulterers and breastfeeding an adult ten times was eaten by a sheep.
59. Arguments about killing adulterers being practiced even among monkeys.
60. Prohibition of a man wearing golden ornaments.
61. Prohibition of men wearing silk.
62. Prohibition of use of golden and silver utensils and plates.
63. Prohibition of sculpture.
64. Prohibition of drawing and painting.
65. Prohibition of chess.
66. Prohibition of musical instruments and music.
67. Prohibition of consumption of seafood like mussels, shrimp, etc.
68. That smoking is religiously Haram.
69. That there is a separate list containing things considered to be abominable (makruh).
70. That the sexual act must take place under covers.
71. The prohibition for the couple to look at each other’s sexual organs.
72. Prohibition of masturbation.
73. Prohibition for women to use birth control.
74. That an individual should keep his/her sexual organs covered even when taking a bath lest the angels be offended.
75. Circumcision of men.
76. Circumcision of women.
77. The Sunnah of letting beards grow.
78. The prohibition of trimming a beard.
79. The Sunnah according to which the hair had to be parted from the middle of the scalp.
80. The Sunnah regarding the oiling of hair.
81. The Sunnah of applying henna to hair and beard.
82. The Sunnah of applying mascara to the eyes for men.
83. That lying face down is a satanic act.
84. To sleep on a mattress spread on the ground.
85. To use one’s right foot going out of the house or getting up from the bed.
86. To enter a soiled place like a WC with the left foot.
87. Saying that canonical purification of the body can only be performed using water after defecating.
88. The obligation for men to crouch when urinating.
89. The relieve yourself in the direction of Mecca.
90. The fact that eating with the left hand is a satanic act.
91. To wind a turban on head is Sunnah.
92. To use miswak to clean the teeth.
93. To wear a robe with a long skirt reaching down to one’s feet.
94. For men to wear a loose dress (antari). .
95. To wear shalwar (a type of wide trousers) as Sunnah.
96. To interpret as a meritorious act the wearing of white, green or black raiment.
97. The prohibition to wear yellow or red.
98. To consider eating dates or squash as meritorious acts.
99. To eat seated on the ground.
100. To eat from the same dish with others.
101. To eat with three fingers.
102. To drink water in three gulps.
103. To drink water in a seated position.
104. To lick one’s fingers after having eaten with them.
105. Not to use perfumes containing alcohol.
106. To kill black dogs.
107. Not to let dogs into the home.
108. To cover the mirrors at night.
109. To perform black magic with or without the use of the Quran.
110. To write on and wear amulets.
111. To use the Quran as a book of magic.
112. To believe that whistling is a satanic act.
113. To knock on wood or wear trinkets against the evil eye.
114. To take fortunetellers and magicians for religious figures.
115. Feasts celebrated at the end of the holy month of Ramadan and on the occasion of sacrifices.
116. To avoid passing underneath a ladder and to consider black cats, black dogs as ominous signs and to melt lead against the evil eye.
117. To believe that there are special days on which linen can be washed and sexual intercourse can be performed.
118. To recite the Mevlit/Mouloud (poem written to celebrate the birth and the death of the Prophet) for the souls of the departed.
119. To hold ceremonies for the soul of the dead on the 7th, 40th and 52nd days after death.
120. Stories concocted about the suffering that the dead is to be subjected to after burial.
121. Rumors about the bridge of Sirat (Pul-e-Sirat) from this world to paradise, more slender than a hair and sharper than a sword and a person’s traversing it riding the animal he sacrificed in this world.
122. The belief that a person who cannot avoid his urine from sprinkling on his clothes shall undergo excruciating torture in the grave.
123. To fast in the place of a dead person.
124. To go on Hajj in the place of a dead person.
125. That tears shed after a death will cause his soul to suffer beyond endurance.
126. To predict the hour of the Day of Judgment.
127. The Muslim Messiah, Mahdi.
128. The Antichrist.
129. To say that Dabba (Creature) has the ears of an elephant, eyes of a hog and head of an ox.
130. The Second Coming of Jesus Christ/Isa.
131. The belief that Agog and Magog are Turks.
132. Racism, superiority of the Arabic race.
133. The belief that Agog and Magog are the homunculus.
134. To set down prayer hours not indicated in the Quran.
135. To proscribe a certain number of rakats as a binding duty.
136. The requirement of performing the salat by reciting verses in the original Arabic language.
137. Prohibition for women to conduct the congregational prayer.
138. To have to repeat always the same thing during the kneeling and prostrating in the course of the performance of the salat.
139. The obligation to recite the fatiha at every rakat.
140. The obligation to sit and recite attahiyyat at the end of the salat.
141. To make a long list of the particular requirements during the salat not mentioned in the Quran.
142. To make a detailed description of the praying man with regard to his posture, such as how he will place his hands).
143. That the compensation of a willfully broken fast is two months without interruption.
144. Special salats like the taravih (the superfluous night service during the month of Ramadan performed immediately after the prescribed night service of worship, consisting of twenty genuflections with an interval for rest and breathing after each two or four acts), and the congregational prayers at the end of the month of fasting and at the festival of sacrifice.
145. To put people in misery by restricting the period of Hajj to a short space of time.
146. The stoning of Satan during the Hajj.
147. To slaughter animals at the Festival of Sacrifice.
148. To believe that certain restrictions start after the Hajj.
149. Calling holy the water from the well zamzam, to pray over sugar or salt for luck.
150. To give zakat (alms, charity) as 2.5% of one’s assets.
151. To assign special rates for zakat for camels, sheep and agricultural products.
152. The belief that one invalidates his ablution by certain acts other than nature’s call.
153. The belief that total ablution (Ghusl) is required not only after sexual intercourse and using a toilet but also by other causes.
154. To make the order of acts during the performance of ablution strictly binding.
155. To say that rinsing one’s mouth and blowing one’s nose during the major ablution is a binding duty.
156. The requirement of washing one’s heels along with the feet.
157. Details such as the obligation of pouring water three times each to the right and left of a person performing the total ablution.
158. The requirement of total ablution before reciting the Quran.
159. Saying that one sins when he/she goes about not having performed total ablution.
160. The nullification of ablutions for a person who has a tooth filled.
161. The nullification of ablutions for men/women having a tattoo.
162. Martyrdom for those having died in an earthquake or a flood.
163. Martyrdom of those having suffered stomach pains.
164. That the earth is supported by an ox or a fish.
165. The belief that earthquakes occur when the fish shakes its tail.
166. Eight (angels in the form of) mountain goats supporting the throne of God.
167. The sun set and goes under the throne of God and seek permission to rise again.
168. The belief that the eclipses of the sun and the moon occur when they are drawn by carriages equipped with handles.
169. Existence of angels in the form of bulls, lions and eagles.
170. Accounts related to the 600 wings of Gabriel.
171. God’s opening His calf in paradise.
172. God’s touching the back of the Prophet.
173. God’s coming down on earth on special days to shake the hands of His creatures.
174. The bargaining between God and the Prophet for the reduction of the times of salat from 50 down to 5.
175. Institution of the caliphate.
176. The sultanate and the making the subjects into slaves of the political power.
177. Classes of clergy.
178. To sanctify the Arabic language and ascribe sanctity to the Arabic letters.
179. To terrorize people with the countries outside the dominion of Islam (Dar-ul Harb).
180. To loot and disregard the rights of people living outside the dominion of Islam.
181. To beat or kill persons who refuse to perform salat.
182. To compel people to fast and beat those who fail to do so.
183. To beat women who have put on makeup and go around uncovered.
184. To kill the renegades/apostate (of Islam to other religions).
185. To flog the renegades (even those who convert from one sect to another).
186. To make conquests merely for the sake of looting.
187. To beat drunkards.
188. To use force and compel people to abide by religious rules.
189. To call Islam by the names of sects, etc.

NEXT DOCT APPT

next doct appt

eyes                  - 21/10/2015 , Metro SC

Cardiothoracic - 28/10/2015 , Penang GH

Hopefully semua k, inshaALLAH

POST CABG

alhamdulillah , luka pun semakin kering dan baik dan saya dah boleh pakai seluar dah, cuma bahagiaan dada tu rasa sore/ngilu jer lah dan ini akan ambil masa sikit untuk hilang.. Lain2 k ..

APPT WITH EYE SPECIALIST - 7/10/15

today appointment with my eye specialist to check about my long time eye problem, my EPISCLERITIS, hope they already got medicine for this problem.

INSHA ALLAH ada ubat nya....untuk masaalah sya ni....

IMPORTANT DATE - 7/9/2015

hari ni genap 1 month i did my CABG and so far progress as below:

• all wounds dried and getting better.
• light walking and movement , ok
• eating k,but controlled food only, not any foods.
• memory and light work k..
• pending physio programme (wait for letter from Hospital)

FOLLOW UP - 5/10/2015

Follow up results

• doctor satisfied with the conditions of the wounds
• doctor ask to exercise more using the gauge/meter for my left lung
• next appointment will be on 28/10/2015, x ray followed by check up by MO
• follow up with GH Penang will take between 3 to 6 months then will transfer to Metro SC
• waiting for letter from Physio, to start on the planned physio at Penang GH
• Sore at chest area, will disappear over time and hopefully soon, this is the only are where i don't feel comfortable
• No medicine given during this follow up.

Hope for fast recovery , InshaALLAH......

SAKIT MATA - EPISCLERITIS

tadi dah gi ambil GL from my panel doctor, tommorrow going to see my eye specialist to check on my long over due eye problems...Hope he already got medicine to treat my unique eye problems..

already having this problem for years, hope ada cure adn medicine dah for this problems, its painful when at its peak...

POST CABG - MY NEXT APPT OCT 2015

My next appointment will be as below:

1. 5/10/2015 - X ray and see MO
2. 28/10/2015 - x ray and see MO

hopefully everything is k, inshaa ALLAH..

THE OP AT MY CHEST

what actually the surgeon did, they cut my sternum and open up for them to work at my heart...The  images can give some idea how it was done by the surgeon. My chest/sternum area ada rasa sore and tightness...

OCT 2015 - POST OP CABG

Nothing much tunggu baik luka2 di tangan, kaki dan dada, lepas tu my theraphy sebelum dapat kerja, bawa kereta, jogging, biking dan lain2 semula. Physio dan docts akan monitor dan tentukan, mungkin akan ambil masa 6 ke 8 minggu lagi..

luka2 pun semua dah dry dan nak drop off dead cell/tissues  jer dan ada yang dah drop pun.. Sore and tightness cuma bahagiaan dada je dan inshaaALLAH will be k within  4 weeks time lagi kot...

Overall wife jaga dengan baik termasuk makan minum, kebersihan dan sebagainya ini juga faktor yang memprcepatkan proses penyembuhan saya.

RECOVERY AFTER POST CABG (Beyond Basics)

BYPASS SURGERY OVERVIEW

Coronary artery bypass graft surgery, also known as CABG or bypass surgery, can help to restore blood flow to an area of the heart. However, surgery does not stop the progression of atherosclerosis (coronary heart disease), which deposits fatty material into artery walls, narrowing them and eventually limiting blood flow.

Patients and healthcare providers must work together after surgery to treat the underlying atherosclerosis and the factors that can cause progression of heart disease. (See 'Reduce cardiac risk factors' below.)

This topic review discusses treatments that are recommended after coronary artery bypass graft surgery. These treatments can help to:

●

Reduce the risk of developing complications of coronary heart disease, including having a subsequent heart attack or dying.

●

Help a person to feel better and have more energy.

CARE AT HOME AFTER BYPASS SURGERY

Care after bypass surgery aims to reduce the risk factors for heart disease and includes strategies to help patients and family members to stop smoking, control high blood pressure, improve cholesterol levels, begin exercising regularly, and reduce stress. Some of these changes can be made by adjusting lifestyle habits through diet and exercise. However, lifestyle changes alone may not be adequate and medications are often needed.

Discharge from the hospital — Patients with an uncomplicated heart attack usually go home after about five days in the hospital. In some cases, the hospital stay is longer. If complications have occurred, discharge is delayed until the person's condition is stable.

Before leaving the hospital, it is important for the patient and family to participate in and understand the discharge plan. Make sure all questions are answered and obtain written directions for how to take all medications (new and old). After bypass surgery, it is common to start new medications and stop or adjust the doses of previous medications.

Medications — Most people who have had bypass surgery are sent home with prescriptions for several medications, most of which are taken every day. Some of these drugs improve survival and some help to prevent or treat recurrent chest pain.

●

Antiplatelet therapy – Clopidogrel (brand name: Plavix) and aspirin are antiplatelet medications that are given to help prevent the formation of blood clots that can block either the graft or your own arteries. Clopidogrel is continued for at least one year after surgery while aspirin is usually recommended indefinitely. (See "Patient information: Aspirin in the primary prevention of cardiovascular disease and cancer (Beyond the Basics)".)

●

Beta blockers – Beta blockers slow the heart rate, lower blood pressure, and decrease the heart's demand for oxygen. They are given to some patients with high blood pressure, heart failure, or a heart attack, and to some patients in whom bypass surgery is not expected to relieve all symptoms of angina. If a person cannot tolerate a beta blocker, a calcium channel blocker may be substituted.

●

Nitrates – A nitrate, either as short-acting nitroglycerin, or as a long-acting preparation (isosorbide mononitrate or dinitrate). These drugs dilate coronary blood vessels, bringing more blood to the heart muscle. Nitrates also reduce the amount of blood returning to the heart, which decreases the heart's demand for oxygen. Nitrates are often given to treat or prevent further episodes of chest pain. Nitrates may be given to patients after bypass surgery if some of the coronary blood vessels could not be bypassed. (See "Patient information: Medications for angina (Beyond the Basics)".)

●

ACE inhibitor – Angiotensin converting enzyme (ACE) inhibitors are often used to treat high blood pressure.

Examples of ACE inhibitors include captopril (brand name: Capoten), enalapril (brand name: Vasotec), lisinopril (sample brand names: Zestril or Prinivil), and ramipril (brand name: Altace). 

Some patients who cannot tolerate an ACE inhibitor (often because of a chronic cough) may be prescribed an angiotensin II receptor blocker (ARB). These related drugs are satisfactory replacements. 

Examples of ARBs include losartan (brand name: Cozaar), valsartan (brand name: Diovan), and irbesartan (brand name: Avapro).

●

Lipid lowering therapy – Almost all patients are given a medication to lower lipids after CABG. Cholesterol lowering can be beneficial both before and after CABG because it can halt the progression of atherosclerosis in both native and graft vessels.

●

Other medications – Other medications may be given on a short-term basis to prevent the development of an irregular heart, to manage discomfort associated with healing incisions, or to allow for regular bowel movements.

Lipid therapies are recommended even for patients who have values that are in the "normal" range. The goal level for "bad" cholesterol (called LDL or low density lipoprotein) is less than 70 mg/dL (1.8 mmol/L). (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Statins are the most common medications used to lower cholesterol levels. Other drugs may be used as well (table 1).

Wound care — After discharge from the hospital, the patient is usually given instructions about how to care for their chest and/or leg wounds. It is important to follow these instructions closely and to notify a healthcare provider immediately if there are questions or concerns.

●

Avoid heavy lifting and extremes of shoulder movement (eg, as in tennis, baseball, and golf) for six to eight weeks after surgery to allow for complete healing of the breast bone (sternum)

When to seek help — If the patient develops any of the following signs or symptoms of wound infection, a healthcare provider should be contacted immediately. Most wound infections develop within 14 days of the surgery.

●

Fever greater than 100.4º F (38º C)

●

New or worsened pain in the chest or around the incision

●

A rapid heart rate

●

Reddened skin, bleeding or pus-like drainage from the incision

CARDIAC REHABILITATION

Most people who have undergone bypass surgery benefit from participating in a structured, comprehensive cardiac rehabilitation program. People who participate in cardiac rehabilitation usually have appointments several times per week in a hospital or clinic, allowing the person to live and sleep at home. The potential benefits of rehabilitation include an improvement in heart function, a lowering of the heart rate at rest and during exercise, and a reduced risk of dying or developing complications from heart disease.

There are several components to cardiac rehabilitation, including exercise, reducing risk factors, and dealing with stress, anxiety, and depression. The benefits of cardiac rehabilitation are seen only when this multifactorial approach is used. In other words, one component alone is not enough.

Exercise — Exercise has consistently been shown to improve cardiovascular health. Importantly, the first step in starting to exercise is to determine the potential risk of heart and/or blood vessel complications from exercise. This is usually done by undergoing a monitored exercise test on a treadmill. Although nearly everyone can exercise safely after discharge, the intensity and duration of exercise should be adjusted according to the severity of a person's heart disease.

Risk categories for exercise — Risk categories are a way of describing a person's risk of cardiovascular (heart-related) complications related to activity. Each category has a unique requirement for supervision and exercise restrictions. People in risk category A are generally healthy, do not require medical supervision during exercise, and have no limitations on the duration or intensity of exercise. Conversely, people in exercise category D have strict limits on activity and should not exercise, even with close medical supervision. Most people who have had bypass surgery are in category B or C.

●

Class A – Individuals who are apparently healthy and in whom there is no evidence of increased heart-related risk with exercise.

●

Class B – Individuals with established coronary heart disease that is stable. These individuals are at low risk of heart-related complications with vigorous exercise.

●

Class C – Individuals who are at moderate or high risk of heart-related complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group.

●

Class D – Individuals with unstable disease who should not participate in an exercise program.

Exercise — During cardiac rehabilitation, a trained clinician will work with the patient and the patient’s main healthcare provider to develop an exercise program that is safe and beneficial. The program will consider the patient's fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision.

●

Type of exercise – The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, cycling, rowing, and stair climbing are some examples.

●

Frequency – The recommended frequency of exercise is three to five times a week.

●

Content and duration – It is important that each session consist of a 5- to 10-minute warm-up phase, a conditioning phase of at least 20 minutes, and a 5- to 10-minute cool-down phase. Eliminating the cool-down phase can increase the risk of heart-related complications.

●

Intensity – One of the most important components of the exercise prescription is the intensity of exercise. This is based upon the patient's heart rate or the level of exertion. A number of formulas exist to calculate the appropriate maximum heart rate for each patient. 

The patient gauges the level of exertion during an activity by rating it on a standardized scale called the rating of perceived exertion (RPE) (table 2). Moderate-intensity exercise (an RPE of 12 to 13) is needed to achieve cardiovascular health benefits. The benefits of very high intensity exercise are small; intense exercise is not recommended because it leads to muscle fatigue and increases the risk of physical injury and cardiovascular complications.

●

Exercise progression – Over time, most people can gradually increase the level of exercise in the workout. Beneficial exercise can also be built in to the daily routine by taking a brisk walk or enjoying active play with children or grandchildren.

●

Supervision – Patients who are in Class C should be in a medically supervised program where the electrocardiogram (ECG) is monitored during exercise. Advanced life support equipment (eg, a defibrillator, medications, personnel trained to use this equipment) should be on hand. This level of supervision should continue for at least 8 to 12 weeks. 

Lower-risk patients (Class B) benefit from a medically supervised, ECG-monitored program for the first 6 to 12 sessions. Following this, a home-based exercise program is safe and effective.

REDUCE CARDIAC RISK FACTORS

A number of factors increase the risk of developing or speeding the progression of heart disease. Reducing or eliminating these risk factors can be helpful, even if a person already has heart disease or has had a heart attack. Strategies to reduce risks are discussed below.

Follow a heart healthy diet — Diet counseling is helpful for people who need to lose weight or reduce cholesterol levels. A registered dietitian is the best person to consult about foods that are helpful and harmful, appropriate portion sizes, total calorie recommendations, and realistic ways to change bad eating habits.

Most cardiac rehabilitation programs have a dietitian who is knowledgeable and experienced in advising people who are recovering from a heart attack. (See "Patient information: Diet and health (Beyond the Basics)".)

Stop smoking — Cigarette smoking significantly increases the risk of coronary heart disease and heart attack, and stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half and the risk continues to decline with time. In some studies, the risk of heart attack was reduced to the rate of nonsmokers within two years of quitting smoking.

Cardiac rehabilitation programs can recommend a treatment to help stop smoking, such as group programs; nicotine patches, gum, or nasal spray; or a prescription medication. (See "Patient information: Quitting smoking (Beyond the Basics)".)

Treat high blood pressure and high cholesterol — Medicines to control high blood pressure and high cholesterol are usually recommended after bypass surgery. (See 'Medications' above.) It is important to take these medications exactly as prescribed. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)" and"Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Manage diabetes — People with diabetes are at an increased risk of developing complications after bypass surgery. Tight control of blood glucose levels can help to reduce the risk of these and other types of complications. Tight control can be achieved by losing weight, managing the diet, exercising, monitoring blood glucose levels regularly, and taking oral hypoglycemic medications (for people with type 2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes). (See "Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)".)

Psychosocial treatment — Feelings of depression, anxiety, and denial are common after bypass surgery, occurring in up to 40 percent of people. Depression can reduce a person's ability to exercise, decrease energy levels, cause more fatigue, or reduce a person's quality of life and sense of well-being. Women, and in particular younger women, are at an especially high risk for depression.

These symptoms can cause problems within the family, marriage, and the workplace. Individual or group therapy, and sometimes treatment with an antidepressant medication, can be helpful. Many cardiac rehabilitation programs have trained personnel, including psychologists, psychiatrists, or social workers, to help manage these issues. Treating depression and anxiety can improve a person's long-term outlook and general sense of well-being. (See "Patient information: Depression in adults (Beyond the Basics)".)

Reduce stress — Long-term stress in the home, at work, or with finances can increase the risk of heart attack, stroke, and chest pain. Many cardiac rehabilitation programs teach patients how to reduce stress in an attempt to lower these risks.

Stress reduction techniques may include one or more of the following:

●

Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with stress, treatment successes or failures, and/or personal relationships.

●

Group psychotherapy allows patients to compare their experiences with stress and heart disease, overcome their tendency to withdraw and become isolated, and support one another's attempts at more effective management.

●

Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, and biofeedback. Biofeedback may be especially helpful for people with chronic stress.

●

Group skill-building exercises help patients to learn about living with stress and heart disease, including ways to improve relationships and build strength, ways to avoid negative thinking, and learning to deal with stress.

WHEN IS SEX SAFE?

An important issue for many patients who have had bypass surgery is when sexual activity can be safely resumed. In the first two weeks after an uncomplicated heart attack, most people are at high risk of heart-related problems during sex as a result of a rise in the heart rate and blood pressure. However, this risk becomes much smaller by six weeks after the heart attack.

Patients with complications of a heart attack, such as recurrent chest pain, abnormal heart rhythms (arrhythmias), or heart failure are at intermediate or high risk of heart-related problems during sex. People in these risk groups need further evaluation and/or treatment before attempting to have sex. Talk to your healthcare provider if you have questions about when you can safely resume sex.

Sexual problems — Sexual problems after a bypass surgery are common, occurring in one-half to three-quarters of patients. Both men and women may have less sex or feel less satisfied with sexual activity. A variety of factors may contribute, including side effects of drugs (such as beta blockers), depression, and fears about triggering a new heart attack or dying. Since sexual activity is a type of physical activity, exercise testing can be used to determine if a person is at any risk of heart problems related to sex.

Use of Viagra, Cialis or Levitra — For many men with erectile dysfunction, medications such sildenafil (brand name: Viagra), tadalafil (brand name: Cialis) or vardenafil (brand name: Levitra) are highly effective. There have been concerns that these agents might cause side effects or increase the risk of heart attack in people with coronary heart disease. However, if used appropriately, these drugs appear to be well tolerated and safe. (See "Patient information: Sexual problems in men (Beyond the Basics)".)

Unfortunately, these medications are not usually helpful for women with sexual problems after a heart attack or bypass surgery. Other treatments are available for women. (See "Patient information: Sexual problems in women (Beyond the Basics)".)

Nitrates and medications for erectile dysfunction — None of the medications for erectile dysfunction (eg, Viagra, Cialis, Levitra) should be used if a person regularly or intermittently requires nitrates (such as nitroglycerin or isosorbide) for recurrent chest pain. This combination of medications can cause a life-threatening drop in blood pressure.

Thus, if a man develops chest pain after taking Viagra, Cialis or Levitra, he should not take nitrates for 24 hours (or longer in some cases). Instead, the man should rest and wait 10 minutes to see if the pain resolves. If the pain does not resolve or if the chest pain is severe, he should immediately call for emergency medical services (in the United States by calling 911).

FOLLOW-UP CARE

Following the discharge plan and participating in a cardiac rehabilitation program are the best ways to recover from bypass surgery. In addition, it is important to schedule and attend periodic visits with an internal medicine providerand/or cardiac specialist (cardiologist).

Follow-up care is of great importance since people who have had bypass surgery have a significantly increased risk of more cardiac events, including recurrent chest pain, heart attack, heart failure, and an increased risk of dying. The risk of these problems is greatly reduced by closely following a clinician's recommendations for rehabilitation, follow-up visits, and treatments. Over time, the treatment plan may change as heart health improves or other medical problems develop.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Coronary heart disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Coronary artery bypass graft surgery (Beyond the Basics)

Patient information: Aspirin in the primary prevention of cardiovascular disease and cancer (Beyond the Basics)

Patient information: Medications for angina (Beyond the Basics)

Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

Patient information: Diet and health (Beyond the Basics)

Patient information: Quitting smoking (Beyond the Basics)

Patient information: High blood pressure treatment in adults (Beyond the Basics)

Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)

Patient information: Depression in adults (Beyond the Basics)

Patient information: Sexual problems in men (Beyond the Basics)

Patient information: Sexual problems in women (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cardiac rehabilitation in patients with heart failure

Cardiac rehabilitation programs

Cardiac rehabilitation: Evidence of benefit in patients with coronary heart disease

Exercise assessment and measurement of exercise capacity in patients with coronary heart disease

Overview of the therapy of heart failure with reduced ejection fraction

Rehabilitation after cardiac transplantation

Sexual activity in patients with cardiovascular disease

The following organizations also provide reliable health information.

●

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

●

National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov/)

●

American Heart Association

     (www.americanheart.org)

●

Society of Thoracic Surgeons

     (www.sts.org)