What is the appropriate workup and management for a patient 10 days post-Coronary Artery Bypass Grafting (CABG) and Surgical Aortic Valve Replacement (SAVR) presenting with nausea, weakness, poor appetite, and fatigue?

From the Guidelines

For a patient 10 days post-CABG and SAVR presenting with nausea, weakness, poor appetite, and fatigue, a comprehensive evaluation and management approach is crucial to address potential complications and optimize recovery. The patient's symptoms could be indicative of normal post-operative recovery, medication side effects, or complications such as infection, anemia, electrolyte abnormalities, or cardiac issues like heart failure or pericardial effusion 1.

Initial Evaluation

A thorough evaluation should begin with:

• Vital signs assessment
• Physical examination focusing on cardiac and respiratory systems
• Laboratory tests including complete blood count, comprehensive metabolic panel, cardiac enzymes, and BNP
• An ECG to evaluate for arrhythmias or ischemic changes
• A chest X-ray to assess for pleural effusions, pulmonary edema, or pneumonia
• Echocardiography to evaluate valve function, ventricular function, and to rule out pericardial effusion or tamponade

Management

Management typically includes:

• Optimizing fluid status (either restricting or supplementing as needed)
• Adjusting cardiac medications if side effects are contributing to symptoms
• Providing antiemetics such as ondansetron 4mg every 6 hours as needed for nausea
• Ensuring adequate nutritional support
• Considering the potential benefits and risks of weight loss in patients with CAD, as noted in the 2015 scientific statement from the American Heart Association 1

Considerations

It is essential to consider the patient's overall clinical context, including the presence of metabolic syndrome, which has been associated with increased in-hospital mortality and long-term mortality after CABG 1. The management of metabolic syndrome should include lifestyle modification with increased exercise, improved diet, and weight loss, as well as pharmacological treatment for hypertension, diabetes mellitus, and dyslipidemia as needed.

Follow-up

Close follow-up is essential, and if symptoms worsen or if there are concerning findings on initial evaluation, hospital admission may be necessary for more intensive monitoring and management. The patient's medication regimen, including beta-blockers and antiplatelet therapy, should be carefully evaluated and adjusted as needed to minimize potential side effects and optimize outcomes 1.

From the Research

Presentation and Symptoms

• The patient is presenting with nausea, weakness, poor appetite, and fatigue 10 days post-Coronary Artery Bypass Grafting (CABG) and Surgical Aortic Valve Replacement (SAVR) 2, 3.
• These symptoms can be associated with high morbidity and poor quality of life, particularly in those with chronic symptoms 2.
• The clinical approach to these symptoms can be challenging, given the numerous possible underlying causes as well as the vast array of diagnostic and therapeutic options 2, 3.

Differential Diagnosis

• The differential diagnosis for nausea and vomiting is broad and can include gastrointestinal, infectious, metabolic, neurologic, psychiatric, or medication-related causes 2, 3, 4.
• The patient's presentation, severity of symptoms, and physical examination findings should be used to formulate a differential diagnosis and guide evaluation 2, 3.
• Consideration should be given to the patient's recent surgery and potential medication side effects, as well as other possible causes such as gastroenteritis or other viral syndromes 5, 3.

Evaluation and Management

• The evaluation of nausea and vomiting should include a careful history and physical examination, as well as laboratory tests and imaging studies as needed 2, 3, 4.
• Management of symptoms that are acute in onset or mild in severity may involve an empirical trial of antiemetics without extensive testing 2, 3.
• For chronic or moderate-severe symptoms, testing for an underlying cause should be performed, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered in particular 2, 3, 4.
• Post-CABG patients may have different medication needs and respond differently to certain medications, such as aspirin, statins, and β-blockers 5, 6.