The branches of coronary arteries are shown in Fig. 7.1 .

The sinus node is supplied by the RCAin about 50% to 60% of humans and by the LCX in the remaining 40% to 50%. Theatrioventricul ar node (AVN) is provided by the RCA in 85% to 90% of humans and by the LCXin the remaining 10% to 15%; therefore, the RCA is dominant in 85% to 90% of patients. Themost common arteries for coronary artery bypass graft (CABG) surgery are the LADA, theobtuse marginal artery, and the posterior descending artery. View FigureFigure 7.1. Branches of the coronary arteries.Back to Quick LinksBraunwald E, Zipes DP, Libby P, Heart disease, a textbook of cardiovascular medicine 6th ed.Philadelphia: WB Saunders, 2001:394 400.Fuster V, Alexander RW, O'Rouke RA,

Hurst's the heart 10th ed. New York: McGraw-Hill,2001:4488. 1965A.2. What are the indications for coronary artery bypass grafting?The indications for CABG consist of the need for improvement in the quality or quantity of life.Patients whose angina is not controlled by medical treatment or who have unacceptable sideeffects with such management should be considered for coronary revascularization.Percutaneous transluminal coronary angioplasty (PTCA) is currently accepted as the initial procedure of choice in selected patients with obstructive CAD. Since its introduction in 1978,PTCA has redefined the candidates for elective surgic Would you discontinue digoxin? Why? What is its half-life?To prevent digitalis intoxication after cardiopulmonary bypass (CPB), digitalis preparations areusually discontinued one half-life (1.5 to 1.7 days for digoxin, 5 to 7 days for digitoxin) beforesurgery. Digitalis intoxication is quite possible, particularly after CPB when acidbase andelectrolyte levels are abnormal. If the patient is in congestive heart failure (CHF) and digitalisdependent, digitalis is continued until the night before surgery. However, the predisposingfactors to digitalis intoxication, especially hypopotassemia and hypercalcemia, have to be prevented. B.7. Would you discontinue propranolol? Why? What is its half-life? What is the role of the -adrenergic blockers in treating congestive heart failure?Propranolol should be continued not only until surgery, but probably throughout the perioperative period. Propranolol is generally continued until the time of surgery. In patientswith unstable angina, sudden withdrawal of propranolol may produce an exacerbation of symptoms and may precipitate acute myocardial infarction. The dose of propranolol need not bereduced before surgery to avoid bradycardia, hypotension, or difficulty in weaning from CPB.The halflife of oral propranolol is 3.4 to 6 hours. Propranolol disappears from the plasma andatria within 24 to 48 hours after discontinuing doses of 30 to 240 mg per day. It has been shownthat with a 0.5-mg dose of propranolol intravenously, blood levels as high as 50 ng/mL areobtained but rapidly decrease to unmeasurable levels within 5 to 10 minutes. There has been nomyocardial depression seen with these small intravenous doses Reductions in HR with propranolol occur at lower serum levels than depression of myocardialcontractility. Accordingly, as drug levels decrease after discontinuation of therapy, reductions inchronotropic response last longer than reductions in inotropy. This is an important concept intreating tachycardias in patients with significant ventricular dysfunction and CHF. Numerous studies have confirmed improvements in cardiac function, exercise capacity, andlong-term survival in patients with heart failure resulting from myocardial infarction,hypertrophic cardiomyopathy, or idiopathic dilated cardiomy opathy with -antagonists. -Antagonists may also be of benefit in patients with diastolic dysfunction secondary tohypertension.Potential benefits of -adrenergic blockade in heart failure include decreased HR andnormalization of -receptor function. Diastolic function by increasing diastolic filling time,myocardial perfusion, and myocardial oxygen consumption are all improved by slower HRs. Adrenergic receptors are downregulated in heart failure, but their response is normalized bylong-term beta-blockade. Partial -agonists

may provide baseline sympath etic drive but act asantagonists against excessive sympathetic stimulation

If th e pa tie nt w ho

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as hypovolem ia, deep anesth esia, and surgical manipulati on,should be

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agon, calcium, or digitalis to counteract the betablockade.C ardiogenic hypotensio n is usually

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hy po te nsi on int ra op er

atively, how would youmanage it?The specific antagonists for propranolol are not

th ef irs t ch oi ce. Th e

more common causes of in traoperativ e hypotensio n, such as hypovolem ia,

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surgical manipulati on,should be corrected first. In rare instances, it is

ne ce ss ar y to ad mi nis

ter atropine for bradycardia or epinephrine , isoproteren ol, glucagon,

cal ci u m, or di git ali s

to counteract the betablockade.C ardiogenic hypotensio n is usually associated with high

P C W P an d lo w bl

ood pressure (BP If the patient who is on propranolol develops hypotensio

n int ra op er ati ve ly, ho

w would youmanage it?The specific antagonists for propranolol are not the first

ch oi ce. Th e m or e co

mmon causes of in traoperativ e hypotensio n, such as hypovolem ia, deep anesth

esi a, an d su rgi cal m an

ipulation,sh ould be corrected first. In rare instances, it is necessary to

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bradycardia or epinephrine , isoproteren ol, glucagon, calcium, or digitalis to

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ockade.Car diogenic hypotensio n is usually associated with high PCWP and low blood pressure

(B P