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CMAJ | MAY 10, 2021 | VOLUME 193 | ISSUE 19 E689 A bout 15 000 people in Canada undergo coronary artery bypass grafting (CABG) surgery each year.1 According to the 2019 Canadian Institute for Health Information Cardiac Care Quality Indicators Report, 9.4% of these patients are urgently re admitted to hospital within 30 days of CABG surgery.1 As the Can­ ad ian population continues to age, cardiac surgery is being offered to older, sicker and more frail patients; such patients have higher rates of readmission to hospital after surgery.2 A retrospective study showed 30­day readmission rates of 15%–20% in patients older than 80 years undergoing cardiac surgery at a single centre.2 Furthermore, a lack of outpatient primary care practitioner visits within 30 days after discharge was associated with a fivefold increased risk of poor 1­year functional survival (hazard ratio 5.18, p < 0.01).2 These findings highlight the important role that primary care practitioners play in the management of patients following CABG surgery. Most CABG surgeries are performed using cardiopulmonary bypass, which uniquely affects patients’ physiology and leads to specific postoperative complications in some patients. Cardio­ pulmonary bypass facilitates a motionless and bloodless surgical field, while maintaining blood oxygenation and tissue perfusion by circulating the patient’s venous blood through a mechanical oxy­ genator. However, contact of the blood with the nonendothelialized surfaces of the bypass circuit triggers an intense systemic inflamma­ tory response syndrome (SIRS), and leads to activation of the coagu­ lation system. Although heparin is routinely given to mitigate clot­ ting, SIRS also leads to massive fluid shifts, dysregulation of capillary beds and, consequently, tissue hypoperfusion despite fluid reten­ tion.3 Hypoperfusion related to SIRS, combined with micro­emboli, can lead to organ system damage and postoperative morbidity. Patients may develop chest pain, shortness of breath or dysregula­ tion of blood pressure in the weeks after surgery secondary to SIRS. We discuss the management of postoperative clinical syn­ dromes and potential early and late complications that primary care practitioners may encounter. Important medication and activity considerations, based on best practice guidelines and current evidence (Box 1), are also highlighted. It is important to note that CABG performed without cardiopulmonary bypass (“off­pump”) is still a major surgery and patients may have many of the postoperative complications discussed in this review. What causes chest pain after cardiac surgery?

Management of patients after coronary artery bypass grafting surgery: a guide for primary care practitioners