Total Arterial CABG: Why Graft Quality Matters More Than Technique

You do not manage it — you accept it, because that is your best option to open the coronary artery blockage. The bleeding risk is only a problem in a living patient. If the patient dies from a myocardial infarction for lack of intervention, there is no bleeding to manage.

It should be started at the lowest possible dose — half a tablet, 25mg once daily, titrated over a week to 50mg, then 100mg, not typically exceeding 100mg once daily or 50mg twice daily. The primary indication is ejection fraction below 45% with elevated NT-proBNP. In a patient with ejection fraction below 35% and high NT-proBNP, it should be initiated at the lowest dose and titrated carefully upward.

In Africans and Asians, coronary artery disease is largely driven by genetic predisposition. In Caucasians, the predominant driver is sedentary lifestyle combined with diet — high-fat foods, alcohol, physical inactivity — which more than compensates for their lesser genetic predisposition. Surgical outcomes are comparable worldwide, with success rates upward of 90% and combined morbidity and mortality after CABG around 5 to 7% regardless of country. But the numbers in Asia and Africa are hugely underrepresented — if one million cardiac deaths annually in sub-Saharan Africa is the current reported figure, the true number with adequate diagnostic infrastructure would likely be closer to three million.

The traditional Indian vegetarian population was genuinely following something close to this diet. What changed was cooking oil. Industrial cooking oils were repackaged and marketed under omega fatty acid branding — omega-3, then omega-6, now omega-9 — persuading consumers to abandon traditional cooking fats like mustard oil and olive oil for artificially processed, packaged products whose health claims aren't supported by meaningful clinical evidence. If the population simply returned to traditional cooking oils, it would likely cut the cardiac disease burden significantly. The pyramid isn't the problem; the oil in the pan is.

No, it does not. Gyms typically require only a basic medical certificate, not triglyceride, homocysteine or CRP levels. The supplement industry is enormous, largely unregulated and mostly not FDA-approved. And building muscle mass ignores that the heart is also a muscle — when it hypertrophies beyond physiological bounds, that's called hypertrophic cardiomyopathy, not fitness. The footballer Christian Eriksen is instructive: he had a cardiac event at Euro 2020, received an ICD, returned to professional football, and years later the ICD detected and treated an arrhythmic episode with a single defibrillation — he felt dizzy, walked off, and was alive. Shane Warne's death, by contrast, fit the classic pattern: lifelong smoking, crash diets, and heavy alcohol.

Using bilateral internal mammary arteries, both the left and right, as conduits.

Across roughly 850 patients per arm, 13% mortality in the CABG group against 26% in the stenting group at one year, and 28% adverse events against 60%, published in the Annals of Thoracic Surgery.

Not necessarily; a LIMA-only robotic CABG is inferior to a total arterial open CABG, because graft quality matters more than the method used to deploy it.

The surgeon, based on achieving the best quality of conduit, not the patient's preference for a particular technique.