My Review of "Getting Better: A Doctor's Story of Resilience, Recovery, and Renewal"

For those contemplating open-heart surgery, specifically coronary bypass surgery or CABG, this anesthesiologist's detailed description of his experience is a must read

When my dad was 70 he suffered a small heart attack, aka MI, and one of my partners performed an invasive coronary angiogram on him which demonstrated a long, complicated, severe blockage in his right coronary artery. The other two coronary arteries had significant blockages as well and my partner recommended that he undergo coronary artery bypass surgery (aka CABG, pronounced cabbage).

He felt that stenting the right coronary artery, the one we felt was the "culprit" or cause of my dad's MI would require up to 4 stents increasing the risks of the procedure and lowering the chance of long-term patency of the artery. In addition, as was typical of cardiology thinking in the early 2000s, he felt the long-term outcome would be better if the other arteries were bypassed.

After reviewing the coronary angiograms, reviewing the literature, and discussing the options with my dad, we went against my partner's recommendation and asked him to stent just the right coronary artery. This, he reluctantly agreed to.

My dad did great after this thanks to modern cardiac medications and excellent physicians and died 26 years later at the age of 96 (from kidney failure) without any further cardiac issues.

In a recent post focused on helping patients avoid unnecessary procedures (on Substack here), I wrote (mostly skeptically) about coronary artery bypass surgery.

At one time, CABG was the bread and butter of cardiothoracic surgeons with half a million of them performed annually in the U.S.

The studies showing the benefit of CABG over medical therapy in certain patients with severe but stable CAD occurred in an era before the widespread use of statins and other life-saving cardiac medications.

Since 2000 there has been a continuous decline in the number of CABGs performed annually in the US and in the last 10 years a progressive decline in coronary stenting procedures thanks to advances in medical treatment that reduce plaque progression and seminal studies showing that stable CAD does not require revascularization with either CABG or PCI in most cases.

For those who have had CABG or are contemplating the surgery, however, I can highly recommend a book I was recently sent by the publisher entitled "Getting Better: A Doctor's Story of Resilience, Recovery, and Renewal."

The author, Andrew G. Kadar, MD, is an anesthesiologist who underwent CABG 12 years ago at Cedars-Sinai Medical Center.

The book is divided into four parts which deal with the diagnosis of Dr. Kadar's coronary artery disease, his in-hospital experience of bypass surgery, and his short and long-term recovery.

PART I: DENIAL, ACCEPTANCE, AND RESILIENCE

Dr. Kadar was 62 years old, a lifelong athlete who "consistently maintained a health-promoting lifestyle"*** and had no family history of heart disease when he began experiencing chest pain: a burning sensation under his breastbone. He takes us through his thought process which included considering all of the possible causes of such pain from pleuritis to GERD to angina.

His PCP orders a stress test* which is markedly abnormal and the next day he undergoes an invasive coronary angiogram.

Kadar describes in detail the reasons for and the steps involved in both of these tests and his physician perspective adds to the detail.

The angiogram, according to the cardiologist ** showed a 70% circumflex stenosis, an 80% proximal LAD stenosis, and a 99% blockage of the right coronary artery.

He makes the inaccurate statements that "any coronary artery narrowing greater than 50% poses an increased risk of a heart attack" and that blockage of the LAD causes sudden death from fatal heart attacks so often that is called the "widow maker."

Ultimately he was convinced that coronary bypass surgery was his only option because "the pattern of my pathology wiped out the prospect of a successful angioplasty in multiple ways." Readers should keep in mind that his angiogram took place 10 years ago and PCI procedures and techniques have advanced since then.

It is easy to be a Monday morning quarterback in cardiology but if this was my (or my father's) presentation I would have pushed for an attempt at stenting of the right coronary which was clearly the culprit vessel, responsible for the angina he had begun experiencing 10 days earlier. The rest of his blockages and the burden of atherosclerosis in all of his arterial beds were better treated by current preventive cardiology measures

PART II: INITIAL RECOVERY IN THE HOSPITAL

I can enthusiastically recommend this part of the book as it gives readers a great understanding of what they will be feeling and experiencing on a day-to-day basis after a bypass operation.

I've taken care of hundreds of patients post-bypass and have seen lots of different complications. It is remarkable how many things can go wrong. Dr. Kadar does a great job of describing some of the complications he experienced.

He goes into atrial fibrillation, something we see in about a third of patients after bypass surgery. Medical treatment is initiated and his heart rate slows and he returns to normal rhythm.

His blood pressure remains low and requires additional medical treatment.

By post-op day 3 pain from the incisions has subsided to "an intermitten dull ache" but he finds that solid foods would stick in his throat. "Every meal descended into an ugly and tortuous bout of choking, coughing, and retching with tears streaming from my eyes and saliva mixed with bits of food dripping from my mouth."

The physicians and staff taking care of him were not responding to this issue to his satisfaction so he calls a gastroenterologist friend who suggests getting an esophagram which his PCP orders. Ultimately, the diagnosis of pharyngeal palsy is made an ENT specialist sees him and tells him the complication is common after open-heart surgery, the cause is unknown and that it will slowly improve (which it does.)

Kadar begins having hiccups right after surgery and every hiccup caused a jolt of pain from his chest incisions. After his chest tubes were removed these became very frequent and bothersome, requiring treatment with baclofen which then made him incredibly drowsy.

He also develops phlebitis or vein inflammation at the site of a prior IV line.

With each of these problems, Kadar provides readers with a basic understanding of the processes involved, the impact on the patient, and the treatment options available.

I particularly liked Chapter 9 of this section which is a great rumination on intravenous (IV) lines. Anesthesiologists like Dr. Kadar are generally the masters of starting IV lines. In the hospital, however, you will not be getting your veins poked by an anesthesiologist. I recall going in for major surgery once and being stuck multiple times unsuccessfully. I had to ask for the anesthesiologist to start the IV. Dr Kadar describes a similar experience.

THE CLOSING ARGUMENTS

In the last chapter of his book, Kadar writes:

I wrote this book primarily for people facing surgery, long-term illness, or hospitalization and for their loved ones. I wanted to provide hope for those confronting a difficult and painful recovery, and to describe some medical pro-cedures, the rationale behind them, and the process of recuperation. Knowing what's going on can make it easier for patients to understand and accept what they need to do to help themselves heal. And seeing that others have traveled down the same road with good results can be encouraging.

Despite my critical notes on the book, I do feel it succeeds in reaching the goals the author describes above.

Kadar writes "A note of caution here: you or your loved one will not face the same sequence of complications and challenges, nor the same path to recovery that I went through. However, I believe that there will be enough similarities to make my story informative and helpful."

Indeed, every patient undergoing CABG will have a unique experience. Some will sail through with minimal pain and no complications with discharge on day 4. Some will develop renal failure, sternal wound infections, stroke or cardiac tamponade. Some will die on the table, others will die later from these complications.

An otherwise healthy 62-year-old man undergoing just bypass grafting during open heart surgery has about a 2% chance of dying within 30 days of the surgery.

(Readers should be aware that cardiothoracic surgeons may want to add procedures (like LAAO or mitral valve repair) to the operation that can add substantially to the risks of death and complications. Make sure you know exactly what is being done to your heart during the proposed operation and why.)

Consider reading "Getting Better" to give you better insight into what you will face should you choose the surgical option for treatment of your coronary artery blockages.

Brassically Yours,

-ACP

*We can discuss for days and days the best approach to a patient presenting with new-onset chest pain in 2024. Twenty years ago my approach to many patients would be a stress test, typically coupled with myocardial perfusion imaging. In the last 10 years it has typically been a coronary CT angiogram. I would definitely not have done a stress test on Dr. Kadar had I seen him 12 years ago.

**The invasive coronary angiogram presents the cardiologist with two views of the coronary arteries. From those views an assessment of the percent narrowing of the arterial channel or lumen compared to a theoretically normal nearby portion is determined qualitatively. This entirely subjective assessment lacks precision and reproducibility. One cardiologist's 50% narrowing or stenosis is another's 80% and both evaluations are biased by many factors unrelated to the visual images.

***Near the end of the book Dr. Kadar reveals that he had been diagnosed with high cholesterol but had declined statin therapy thinking that his diet, lifestyle, and good family history indicated he didn't need it.

Years before my surgery, when my cholesterol first registered at a number high enough to treat, I resisted starting medication. I argued with my doctor and myself,
"Taking a statin is beneficial for most people with high cholesterol, but the data wasn't collected on men like me with a great family history and low blood pressure.
I work out, have never smoked and am not overweight.
How do we know that the benefits outweigh the risks in someone like me?"
For about five years, I tried an alternative strategy—a lower fat diet and hope. When that failed to produce the desired result, I started taking a statin and lowered my cholesterol level to the recommended range. By the time my heart symptoms started, my cholesterol had been under good control for over seven years.
We've all made decisions that may have adversely affected our health. When an illness hits, it's normal to question what we might have done differently to avoid getting sick. I've examined and reexamined my medical history in agonizing detail, searching for what I might have done differently if able to turn back the clock. The best I can come up with is starting on a statin sooner.