Patient information: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)

BYPASS SURGERY OVERVIEW

Coronary artery bypass graft surgery, also known as CABG or bypass surgery, can help to restore blood flow to an area of the heart. However, surgery does not stop the progression of atherosclerosis (coronary heart disease), which deposits fatty material into artery walls, narrowing them and eventually limiting blood flow.

Patients and healthcare providers must work together after surgery to treat the underlying atherosclerosis and the factors that can cause progression of heart disease. (See 'Reduce cardiac risk factors' below.)

This topic review discusses treatments that are recommended after coronary artery bypass graft surgery. These treatments can help to:

 

• 
  Reduce the risk of developing complications of coronary heart disease, including having a subsequent heart attack or dying


• 
  Help a person to feel better and have more energy.

 

An overview of coronary artery bypass graft surgery is discussed in detail separately. (See "Patient information: Coronary artery bypass graft surgery (Beyond the Basics)".)

CARE AT HOME AFTER BYPASS SURGERY

Care after bypass surgery aims to reduce the risk factors for heart disease and includes strategies to help patients and family members to stop smoking, control high blood pressure, improve cholesterol levels, begin exercising regularly, and reduce stress. Some of these changes can be made by adjusting lifestyle habits through diet and exercise. However, lifestyle changes alone may not be adequate and medications are often needed.

Discharge from the hospital — Patients with an uncomplicated heart attack usually go home after about five days in the hospital. In some cases, the hospital stay is longer. If complications have occurred, discharge is delayed until the person's condition is stable.

Before leaving the hospital, it is important for the patient and family to participate in and understand the discharge plan. Make sure all questions are answered and obtain written directions for how to take all medications (new and old). After bypass surgery, it is common to start new medications and stop or adjust the doses of previous medications.

Medications — Most people who have had bypass surgery are sent home with prescriptions for several medications, most of which are taken every day. Some of these drugs improve survival and some help to prevent or treat recurrent chest pain.

 

• 
  Antiplatelet therapy — Clopidogrel (brand name: Plavix®) and aspirin are antiplatelet medications that are given to help prevent the formation of blood clots that can block either the graft or your own arteries. Clopidogrel is continued for at least one year after surgery while aspirin is usually recommended indefinitely. (See "Patient information: Aspirin and cardiovascular disease (Beyond the Basics)".)


• 
  Beta blockers — Beta blockers slow the heart rate, lower blood pressure, and decrease the heart's demand for oxygen. They are given to some patients with high blood pressure, heart failure, or a heart attack, and to some patients in whom CABG is not expected to relieve all symptoms of angina. If a person cannot tolerate a beta blocker, a calcium channel blocker may be substituted.


• 
  Nitrates — A nitrate, either as short-acting nitroglycerin, or as a long-acting preparation (isosorbide mononitrate or dinitrate). These drugs dilate coronary blood vessels, bringing more blood to the heart muscle. Nitrates also reduce the amount of blood returning to the heart, which decreases the heart's demand for oxygen. Nitrates are often given to treat or prevent further episodes of chest pain. Nitrates may be given to patients after CABG if some of the coronary blood vessels could not be bypassed. (See "Patient information: Angina treatment — medical therapy (Beyond the Basics)".)


• 
  ACE inhibitor — Angiotensin converting enzyme (ACE) inhibitors are often used to treat high blood pressure.
  
  Examples of ACE inhibitors include captopril (brand name: Capoten®), enalapril (brand name: Vasotec®), lisinopril (sample brand names: Zestril® or Prinivil®), and ramipril (brand name: Altace®).
  
  
  
  Some patients who cannot tolerate an ACE inhibitor (often because of a chronic cough) may be prescribed an angiotensin II receptor blocker (ARB). These related drugs are satisfactory replacements.
  
  
  
  Examples of ARBs include losartan (brand name: Cozaar®), valsartan (brand name: Diovan®), and irbesartan (brand name: Avapro®).

 

 

• 
  Lipid lowering therapy — Almost all patients are given a medication to lower lipids after CABG. Cholesterol lowering can be beneficial both before and after CABG because it can halt the progression of atherosclerosis in both native and graft vessels.


• 
  Other medications „Ÿ Other medications may be given on a short term basis to prevent the development of an irregular heart, to manage discomfort associated with healing incisions, or to allow for regular bowel movements.

 

Lipid therapies are recommended even for patients who have values that are in the "normal" range. The goal level for "bad" cholesterol (called LDL or low density lipoprotein) is less than 70 mg/dL (1.8 mmol/L). (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Statins are the most common medications used to lower cholesterol levels. Other drugs may be used as well (table 1).

Wound care — After discharge from the hospital, the patient is usually given instructions about how to care for their chest and/or leg wounds. It is important to follow these instructions closely and to notify a healthcare provider immediately if there are questions or concerns.

 

• 
  Avoid heavy lifting and extremes of shoulder movement (eg, as in tennis, baseball, and golf) for six to eight weeks after surgery to allow for complete healing of the breast bone (sternum)

 

When to seek help — If the patient develops any of the following signs or symptoms of wound infection, a healthcare provider should be contacted immediately. Most wound infections develop within 14 days of the surgery.

 

• 
  Fever greater than 100.4º F (38º C)


• 
  New or worsened pain in the chest or around the incision


• 
  A rapid heart rate


• 
  Reddened skin, bleeding or pus-like drainage from the incision

 

CARDIAC REHABILITATION

Most people who have undergone bypass surgery benefit from participating in a structured, comprehensive cardiac rehabilitation program. People who participate in cardiac rehabilitation usually have appointments several times per week in a hospital or clinic, allowing the person to live and sleep at home. The potential benefits of rehabilitation include an improvement in heart function, a lowering of the heart rate at rest and during exercise, and a reduced risk of dying or developing complications from heart disease.

There are several components to cardiac rehabilitation, including exercise, reducing risk factors, and dealing with stress, anxiety, and depression. The benefits of cardiac rehabilitation are seen only when this multifactorial approach is used. In other words, one component alone is not enough.

Exercise — Exercise has consistently been shown to improve cardiovascular health. Importantly, the first step in starting to exercise is to determine the potential risk of heart and/or blood vessel complications from exercise. This is usually done by undergoing a monitored exercise test on a treadmill. Although nearly everyone can exercise safely after discharge, the intensity and duration of exercise should be adjusted according to the severity of a person's heart disease.

Risk categories for exercise — Risk categories are a way of describing a person's risk of cardiovascular (heart-related) complications related to activity. Each category has a unique requirement for supervision and exercise restrictions. People in risk category A are generally healthy, do not require medical supervision during exercise, and have no limitations on the duration or intensity of exercise. Conversely, people in exercise category D have strict limits on activity and should not exercise, even with close medical supervision. Most people who have had bypass surgery are in category B or C.

 

• 
  Class A — Individuals who are apparently healthy and in whom there is no evidence of increased heart-related risk with exercise.


• 
  Class B — Individuals with established coronary heart disease that is stable. These individuals are at low risk of heart-related complications with vigorous exercise.


• 
  Class C — Individuals who are at moderate or high risk of heart-related complications during exercise. Examples of people who would be in this category are those who have had several heart attacks and those who have chest pain at a relatively low level of exercise. Patients with certain positive findings on an exercise test may also be in this group.


• 
  Class D — Individuals with unstable disease who should not participate in an exercise program.

 

Exercise — During cardiac rehabilitation, a trained clinician will work with the patient and physician to develop an exercise program that is safe and beneficial. The program will consider the patient's fitness level, heart health, any physical limitations, the amount, intensity and duration of exercise needed to improve heart health, and the need for supervision.

 

• 
  Type of exercise — The exercise should use large muscle groups and include aerobic exercise. Walking, jogging, cycling, rowing, and stair climbing are some examples.


• 
  Frequency — The recommended frequency of exercise is three to five times a week.


• 
  Content and duration — It is important that each session consist of a 5- to 10-minute warm-up phase, a conditioning phase of at least 20 minutes, and a 5- to 10-minute cool-down phase. Eliminating the cool-down phase can increase the risk of heart-related complications.


• 
  Intensity — One of the most important components of the exercise prescription is the intensity of exercise. This is based upon the patient's heart rate or the level of exertion. A number of formulas exist to calculate the appropriate maximum heart rate for each patient.
  
  
  
  The patient gauges the level of exertion during an activity by rating it on a standardized scale called the rating of perceived exertion (RPE) (table 2). Moderate-intensity exercise (an RPE of 12 to 13) is needed to achieve cardiovascular health benefits. The benefits of very high intensity exercise are small; intense exercise is not recommended because it leads to muscle fatigue and increases the risk of physical injury and cardiovascular complications.


• 
  Exercise progression — Over time, most people can gradually increase the level of exercise in the workout. Beneficial exercise can also be built in to the daily routine by taking a brisk walk or enjoying active play with children or grandchildren.


• 
  Supervision — Patients who are in Class C should be in a medically supervised program where the electrocardiogram (ECG) is monitored during exercise. Advanced life support equipment (eg, a defibrillator, medications, personnel trained to use this equipment) should be on hand. This level of supervision should continue for at least 8 to 12 weeks.
  
  
  
  Lower-risk patients (Class B) benefit from a medically supervised, ECG monitored program for the first 6 to 12 sessions. Following this, a home-based exercise program is safe and effective.

 

REDUCE CARDIAC RISK FACTORS

A number of factors increase the risk of developing or speeding the progression of heart disease. Reducing or eliminating these risk factors can be helpful, even if a person already has heart disease or has had a heart attack. Strategies to reduce risks are discussed below.

Follow a heart healthy diet — Diet counseling is helpful for people who need to lose weight or reduce cholesterol levels. A registered dietitian is the best person to consult about foods that are helpful and harmful, appropriate portion sizes, total calorie recommendations, and realistic ways to change bad eating habits.

Most cardiac rehabilitation programs have a dietitian who is knowledgeable and experienced in advising people who are recovering from a heart attack. (See "Patient information: Diet and health (Beyond the Basics)".)

Stop smoking — Cigarette smoking significantly increases the risk coronary heart disease and heart attack, and stopping smoking can rapidly reduce these risks. One year after stopping smoking, the risk of dying from coronary heart disease is reduced by about one-half and the risk continues to decline with time. In some studies, the risk of heart attack was reduced to the rate of nonsmokers within two years of quitting smoking.

Cardiac rehabilitation programs can recommend a treatment to help stop smoking, such as group programs, nicotine patches, gum, or nasal spray, or a prescription medication . (See "Patient information: Quitting smoking (Beyond the Basics)".)

Treat high blood pressure and high cholesterol — Medicines to control high blood pressure and high cholesterol are usually recommended after bypass surgery (see 'Medications' above). It is important to take these medications exactly as prescribed. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)" and "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)

Manage diabetes — People with diabetes are at an increased risk of developing complications after bypass surgery. Tight control of blood glucose levels can help to reduce the risk of these and other types of complications. Tight control can be achieved by losing weight, managing the diet, exercising, monitoring blood glucose levels regularly, and taking oral hypoglycemic medications (for people with type 2 diabetes) or insulin (for people with type 1 and sometimes type 2 diabetes). (See "Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)".)

Psychosocial treatment — Feelings of depression, anxiety, and denial are common after bypass surgery, occurring in up to 40 percent of people. Depression can reduce a person's ability to exercise, decrease energy levels, cause more fatigue, or reduce a person's quality of life and sense of well-being. Women, and in particular younger women, are at an especially high risk for depression.

These symptoms can cause problems within the family, marriage, and the workplace. Individual or group therapy, and sometimes treatment with an antidepressant medication, can be helpful. Many cardiac rehabilitation programs have trained personnel, including psychologists, psychiatrists, or social workers, to help manage these issues. Treating depression and anxiety can improve a person's long-term outlook and general sense of well-being. (See "Patient information: Depression in adults (Beyond the Basics)".)

Reduce stress — Long-term stress in the home, at work, or with finances can increase the risk of heart attack, stroke, and chest pain. Many cardiac rehabilitation programs teach patients how to reduce stress in an attempt to lower these risks.

Stress reduction techniques may include one or more of the following:

 

• 
  Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with stress, treatment successes or failures, and/or personal relationships.


• 
  Group psychotherapy allows patients to compare their experiences with stress and heart disease, overcome their tendency to withdraw and become isolated, and support one another's attempts at more effective management.


• 
  Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, and biofeedback. Biofeedback may be especially helpful for people with chronic stress.


• 
  Group skill-building exercises help patients to learn about living with stress and heart disease, including ways to improve relationships and build strength, ways to avoid negative thinking, and learning to deal with stress.

 

WHEN IS SEX SAFE?

An important issue for many patients who have had bypass surgery is when sexual activity can be safely resumed. In the first two weeks after an uncomplicated heart attack, most people are at high risk of heart-related problems during sex as a result of a rise in the heart rate and blood pressure. However, this risk becomes much smaller by six weeks after the MI.

Patients with complications of a heart attack, such as recurrent chest pain, abnormal heart rhythms (arrhythmias), or heart failure are at intermediate or high risk of heart-related problems during sex. People in these risk groups need further evaluation and/or treatment before attempting to have sex. A cardiologist or internal medicine specialist can help a person to know when sex is safe.

Sexual problems — Sexual problems after a bypass surgery are common, occurring in one-half to three-quarters of patients. Both men and women may have less sex or feel less satisfied with sexual activity. A variety of factors may contribute, including side effects of drugs (such as beta blockers), depression, and fears about triggering a new heart attack or dying. Since sexual activity is a type of physical activity, exercise testing can be used to determine if a person is at any risk of heart problems related to sex.

Use of Viagra®, Cialis® or Levitra® — For many men with erectile dysfunction, medications such sildenafil (brand name: Viagra®), tadalafil (brand name: Cialis®) or vardenafil (brand name: Levitra®) are highly effective. There have been concerns that these agents might cause side effects or increase the risk of heart attack in people with CHD. However, if used appropriately, these drugs appear to be well tolerated and safe. (See "Patient information: Sexual problems in men (Beyond the Basics)".)

Unfortunately, these medications are not usually helpful for women with sexual problems after a heart attack or bypass surgery. Other treatments are available for women. (See "Patient information: Sexual problems in women (Beyond the Basics)".)

Nitrates and medications for erectile dysfunction — None of the medications for erectile dysfunction (eg, Viagra, Cialis, Levitra) should be used if a person regularly or intermittently requires nitrates (such as nitroglycerin or isosorbide) for recurrent chest pain. This combination of medications can cause a life-threatening drop in blood pressure.

Thus, if a man develops chest pain after taking Viagra, Cialis or Levitra, he should not take nitrates for 24 hours (or longer in some cases). Instead, the man should rest and wait 10 minutes to see if the pain resolves. If the pain does not resolve or if the chest pain is severe, he should immediately call for emergency medical services (in the United States by calling 911).

FOLLOW-UP CARE

Following the discharge plan and participating in a cardiac rehabilitation program are the best ways to recover from bypass surgery. In addition, it is important to schedule and attend periodic visits with an internal medicine provider and/or cardiac specialist (cardiologist).

Follow-up care is of great importance since people who have had bypass surgery have a significantly increased risk of more cardiac events, including recurrent chest pain, heart attack, heart failure, and an increased risk of dying. The risk of these problems is greatly reduced by closely following a clinician's recommendations for rehabilitation, follow-up visits, and treatments. Over time, the treatment plan may change as heart health improves or other medical problems develop.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

 

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Coronary heart disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Coronary artery bypass graft surgery (Beyond the Basics)

Patient information: Aspirin and cardiovascular disease (Beyond the Basics)

Patient information: Angina treatment — medical therapy (Beyond the Basics)

Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

Patient information: Diet and health (Beyond the Basics)

Patient information: Quitting smoking (Beyond the Basics)

Patient information: High blood pressure treatment in adults (Beyond the Basics)

Patient information: Preventing complications in diabetes mellitus (Beyond the Basics)

Patient information: Depression in adults (Beyond the Basics)

Patient information: Sexual problems in men (Beyond the Basics)

Patient information: Sexual problems in women (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cardiac rehabilitation in patients with heart failure

Cardiac rehabilitation: Exercise training and secondary prevention of coronary heart disease in older adults

Components of cardiac rehabilitation and exercise prescription

Efficacy of cardiac rehabilitation in patients with coronary heart disease

Exercise assessment and measurement of exercise capacity in patients with coronary heart disease

Overview of the therapy of heart failure due to systolic dysfunction

Rehabilitation after cardiac transplantation

Sexual activity in patients with cardiovascular disease



The following organizations also provide reliable health information.

 

• 
  National Library of Medicine

 

(www.nlm.nih.gov/medlineplus/healthtopics.html)

 

• 
  National Heart, Lung, and Blood Institute

 

(www.nhlbi.nih.gov/)

 

• 
  American Heart Association

 

(www.americanheart.org)

 

• 
  Society of Thoracic Surgeons

 

(www.sts.org)

[1-4]

Literature review current through: Jul 2013. |This topic last updated: Sep 9, 2011.

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The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use©2013 UpToDate, Inc.

References

Top

1. 
   Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143:659.


2. 
   Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005; 111:369.


3. 
   Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115:2675.


4. 
   Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115:2358.

HIGH BLOOD PRESSURE OVERVIEW

Hypertension (high blood pressure) is a common condition that can lead to serious complications if untreated. Making dietary changes and losing weight are effective treatments for reducing blood pressure.

Other lifestyle changes that can help to reduce blood pressure include stopping smoking, reducing stress, reducing alcohol consumption, and exercising regularly. These changes are effective when used alone, but often have the greatest benefit when used together.

An overview of hypertension and a discussion of treatments can be found elsewhere. (See "Patient information: High blood pressure in adults (Beyond the Basics)" and "Patient information: High blood pressure treatment in adults (Beyond the Basics)".) More detailed information is available by subscription. (See "Salt intake, salt restriction, and primary (essential) hypertension" and "Diet in the treatment and prevention of hypertension".)

DIETARY CHANGES AND BLOOD PRESSURE

Making changes in what you eat can help to control high blood pressure.

Reduce sodium — The main source of sodium in the diet is the salt contained in packaged and processed foods and in foods from restaurants. Reducing the amount of sodium you consume can lower blood pressure if you have high or borderline high blood pressure. (See "Salt intake, salt restriction, and primary (essential) hypertension".)

The body requires a small amount of sodium in the diet. However, most people consume more sodium than they need. A low sodium diet contains fewer than 2 grams (2,000 milligrams) of sodium each day.

A detailed discussion of low sodium diets is available separately. (See "Patient information: Low sodium diet (Beyond the Basics)".)

Reduce alcohol — Drinking an excessive amount of alcohol increases your risk of developing high blood pressure. People who have more than two drinks per day have an increased risk of high blood pressure compared to nondrinkers; the risk is greatest when you drink more than five drinks per day.

On the other hand, drinking one (for women) or two (for men) alcoholic beverages per day appears to benefit the heart in people greater than 40 years old. This protective effect applies to people with preexisting high blood pressure. (See "Patient information: Risks and benefits of alcohol (Beyond the Basics)".)

Eat more fruits and vegetables — Eating a vegetarian diet may reduce high blood pressure and protect against developing high blood pressure. A strict vegetarian diet may not be necessary; eating more fruits and vegetables and low-fat dairy products may also lower blood pressure. (See "Diet in the treatment and prevention of hypertension".)

Eat more fiber — Eating an increased amount of fiber may decrease blood pressure. The recommended amount of dietary fiber is 20 to 35 grams of fiber per day. Many breakfast cereals are excellent sources of dietary fiber. More information about increasing fiber is available separately. (See "Patient information: High-fiber diet (Beyond the Basics)".)

Eat more fish — Eating more fish may help to lower blood pressure, especially when combined with weight loss [1].

Caffeine — Caffeine may cause a small rise in blood pressure, although this effect is usually temporary. Drinking a moderate amount of caffeine (less than 2 cups of coffee per day) does not increase the risk of high blood pressure in most people (table 1).

EXERCISE

Regular aerobic exercise (walking, running) for 20 to 30 minutes most days of the week can lower your blood pressure, although the effect is not as pronounced among older adults. To maintain this benefit, you must continue to exercise; stopping exercise will allow your blood pressure to become high again. (See "Patient information: Exercise (Beyond the Basics)".)

WEIGHT LOSS AND BLOOD PRESSURE

Being overweight or obese increases your risk of having high blood pressure, diabetes, and cardiovascular disease. The definition of overweight and obese are based upon a calculation called body mass index (BMI) (calculator 1 and calculator 2). You are said to be overweight if your BMI is greater than 25, while a person with a BMI of 30 or greater is said to be obese. People who are overweight or obese can benefit from losing weight.

To lose weight you must eat less and exercise more. (See "Patient information: Weight loss treatments (Beyond the Basics)".)

WHAT IF I STILL HAVE HIGH BLOOD PRESSURE?

If you continue to have high blood pressure despite making changes in your diet, exercising more, and losing weight, you may need a medication to reduce your blood pressure. Medications for high blood pressure are discussed separately. (See "Patient information: High blood pressure treatment in adults (Beyond the Basics)" and "Choice of therapy in primary (essential) hypertension: Recommendations".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: High blood pressure in adults (The Basics)

Patient information: Controlling your blood pressure through lifestyle (The Basics)

Patient information: Diabetes and diet (The Basics)

Patient information: Renovascular hypertension (The Basics)

Patient information: High blood pressure emergencies (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: High blood pressure in adults (Beyond the Basics)

Patient information: High blood pressure treatment in adults (Beyond the Basics)

Patient information: Low sodium diet (Beyond the Basics)

Patient information: Risks and benefits of alcohol (Beyond the Basics)

Patient information: High-fiber diet (Beyond the Basics)

Patient information: Exercise (Beyond the Basics)

Patient information: Weight loss treatments (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Ambulatory blood pressure monitoring and white coat hypertension in adults

Can therapy be discontinued in well-controlled hypertension?

Cardiovascular risks of hypertension

Choice of therapy in primary (essential) hypertension: Recommendations

Definition, risk factors, and evaluation of resistant hypertension

Diet in the treatment and prevention of hypertension

Hypertension: Who should be treated?

Initial evaluation of the hypertensive adult

Overview of hypertension in adults

Patient adherence and the treatment of hypertension

Prehypertension

Renin-angiotensin system inhibition in the treatment of hypertension

Salt intake, salt restriction, and primary (essential) hypertension

Blood pressure measurement in the diagnosis and management of hypertension in adults

Treatment of hypertension in blacks

Antihypertensive therapy to prevent recurrent stroke or transient ischemic attack

Treatment of hypertension in patients with diabetes mellitus

Treatment of hypertension in patients with heart failure

Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension

Treatment of resistant hypertension

What is goal blood pressure in the treatment of hypertension?

Who should be evaluated for renovascular or other causes of secondary hypertension?



The following organizations also provide reliable health information:

• 
  National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

• 
  National Heart, Lung & Blood Institute (NHLBI)

(www.nhlbi.nih.gov)

• 
  American Heart Association

(www.americanheart.org)

[1-6]

CHRONIC OBSTRUCTIVE PULMONARY DISEASE OVERVIEW

COPD, or chronic obstructive pulmonary disease, is a condition in which the airways in the lungs become damaged, making it increasingly difficult for air to pass in and out.

There are two major kinds of damage that can cause COPD:

• The airways in the lungs can become scarred and narrowed.


• The air sacs in the lung, where oxygen is absorbed into the blood and carbon dioxide is excreted, can become damaged.

When the damage is severe, it may become difficult to get enough oxygen into the blood and to get rid of excess carbon dioxide. These changes lead to shortness of breath and other symptoms.

Unfortunately, the symptoms of chronic obstructive pulmonary disease cannot be completely eliminated with treatment and the condition usually worsens over time. However, treatment can control symptoms and can sometimes slow the progression of the disease.

This article discusses treatment options for people with chronic obstructive pulmonary disease. Treatment of suddenly worsening symptoms, which often requires hospital treatment, is not discussed here. A review of the risk factors and diagnosis of COPD is also available. (See "Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)".)

CHRONIC OBSTRUCTIVE PULMONARY DISEASE MEDICATIONS

Bronchodilators — Medications that help open the airways, called bronchodilators, are a mainstay of treatment for chronic obstructive pulmonary disease. Bronchodilators help to keep airways open and possibly decrease secretions.

Bronchodilators are most commonly given in an inhaled form using a metered dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer. It is important to use the inhaler properly to deliver the correct dose of medication to the lungs. If you do not use the inhaler correctly, little or no medicine reaches the lungs. (See "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)".)

There are several types of bronchodilators that can be used alone or in combination. (See "Management of stable chronic obstructive pulmonary disease".)

• Short-acting beta agonists – Short-acting beta agonists, sometimes called rescue inhalers, can quickly relieve shortness of breath and can be used when needed. Examples of short-acting beta agonists include albuterol, levalbuterol, and pirbuterol.


• Short-acting anticholinergics – Short-acting anticholinergic medication (ipratropium, Atrovent) improves lung function and symptoms. If symptoms are mild and infrequent, short-acting anticholinergic medication may be recommended only when you need it. Or, if symptoms are more severe or more frequent, it may be recommended on a regular basis.


• Short-acting combination inhaler – A combination inhaler that contains albuterol and ipratropium (Combivent) is also available. Combination inhalers may be used just when needed or regularly, depending on the frequency and severity of your symptoms.

Long-acting treatments are often recommended for people who must use medication on a regular basis to control COPD symptoms.

• Long-acting beta agonists – Long-acting beta agonists may be recommended if your symptoms are not adequately controlled with other treatments. Examples of long-acting beta agonists include salmeterol, formoterol, and arformoterol.


• Long-acting anticholinergics – The long-acting anticholinergic medication, tiotropium (Spiriva), which is taken once daily, improves lung function while decreasing shortness of breath and flares of COPD symptoms. Aclidinium (Tudorza), a long-acting anticholinergic that is taken twice daily, also improves lung function. This type of medication may be recommended if your symptoms are not adequately controlled with other treatments, such as the short-acting bronchodilators.


• Theophylline – Theophylline in slow release form (eg, Theo-Dur, Slo-bid) is a long-acting bronchodilator that is taken in pill form. Theophylline is not commonly used, but may be beneficial to some people with more severe, but stable chronic obstructive pulmonary disease. The dose of theophylline must be monitored carefully by blood tests because of its potentially toxic effects.

Glucocorticoids — Glucocorticoids (also called steroids, although they are very different from muscle building steroids) are a class of medication that has anti-inflammatory properties. Glucocorticoids can be taken with an inhaler, as a pill, or as an injection. Inhaled glucocorticoids may be recommended if your symptoms are not completely controlled with bronchodilators and/or if you have frequent flares of chronic obstructive pulmonary disease.

Glucocorticoids taken in pill form are sometimes used for short term treatment (eg, for flares of COPD), but are not generally used long-term because of the risk of side effects.

Combination treatments — Combinations of short and long-acting bronchodilators, anticholinergics, and/or glucocorticoids are often used in people whose symptoms are not completely controlled with one medication.

Cough medicines — Cough medicines are not generally recommended for people with COPD because they have not been shown to improve COPD symptoms. Although cough can be a bothersome symptom, cough suppressants should be avoided since suppressing cough may increase the risk of developing an infection.

SUPPLEMENTAL THERAPIES FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Stop smoking — One of the MOST important treatments for chronic obstructive pulmonary disease is for current smokers to stop smoking. Studies of people with COPD show that the disease progresses more slowly after stopping smoking. Most people who stop smoking will cough less and produce less sputum, although this may take several months. A detailed discussion of ways to quit smoking is available separately. (See "Patient information: Quitting smoking (Beyond the Basics)".)

Oxygen — People with advanced chronic obstructive pulmonary disease can have low oxygen levels in the blood. This condition, known as hypoxemia, can occur even if the person does not feel short of breath or have other symptoms. The oxygen level can be measured with a device placed on the finger (pulse oximeter) or with a blood test (arterial blood gas). People with hypoxemia may be placed on oxygen therapy, which can improve survival and quality of life. (See "Use of oxygen in patients with hypercapnia".)

Some people with COPD who travel by air may be prone to hypoxemia during travel because of the changes in air pressure inside the plane. If a clinician determines that you are at risk for hypoxemia during a flight, in-flight oxygen can be prescribed. (See "Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)".)

Supplemental oxygen must never be used while smoking. Oxygen is explosive, and smoking while using oxygen can lead to severe burns. Fatal fires have occurred in people attempting to smoke while using oxygen.

Nutrition — More than 30 percent of people with severe COPD are not able to eat enough because of their symptoms (shortness of breath, fatigue). Unintended weight loss caused by shortness of breath usually occurs in people with more advanced lung disease. Not eating enough can lead to malnutrition, which can make symptoms worse and increase the likelihood of infection. (See "Nutritional support in advanced lung disease".)

To increase the number of calories you eat:

• Eat small, frequent meals with nutrient-dense foods (eg, eggs)


• Eat meals that require little preparation (eg, microwaveable)


• Rest before meals


• Take a daily multivitamin


• Nutritional supplements (liquids or bars) are also good sources of extra calories because they are easy to eat and require no preparation


• If you continue to lose weight, a prescription medication may be recommended to stimulate your appetite

Pulmonary rehabilitation — Pulmonary rehabilitation programs may include education, exercise training, social support, and instruction on breathing techniques that can ease symptoms of breathlessness. Pulmonary rehabilitation programs have been shown to improve a person's ability to exercise, enhance quality of life, and decrease the frequency of exacerbations of COPD. Even people with severe shortness of breath can benefit from a rehabilitation program. (See "Pulmonary rehabilitation in COPD".)

Surgery — Surgery, such as lung volume reduction surgery or lung transplantation, may be helpful in reducing symptoms in some patients with emphysema.

Lung volume reduction surgery — Lung volume reduction surgery involves removing the areas of lung that are most abnormal, which allows the remaining lung to expand and function more normally. (See "Lung volume reduction surgery in COPD".)

This procedure may be an option for people who have severe symptoms after trying all other routine therapies, including pulmonary rehabilitation. Not all patients will benefit from this surgery, and some may actually become worse. An imaging test, such as a CT scan, may be recommended to help determine if surgery is likely to be of benefit.

Lung transplantation — Lung transplantation may be considered in cases of severe chronic obstructive pulmonary disease. If successful, transplantation is likely to improve symptoms. However, lung transplantation has not yet been shown to prolong the life of people with COPD. (See "Lung transplantation: General guidelines for recipient selection".)

Other therapies — Other treatments for COPD are occasionally recommended, including: noninvasive ventilatory support (the use of a special mask and breathing machine to improve symptoms), anti-anxiety or anti-depressant medications, or morphine-like medications to reduce shortness of breath.

PREVENTION AND TREATMENT OF INFECTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE

People with chronic obstructive pulmonary disease are at risk for worsening symptoms as a result of respiratory infections. Avoiding these infections and treating them quickly if they occur are important parts of COPD therapy.

Vaccines — Everyone with chronic obstructive pulmonary disease should have a pneumococcal vaccination, which helps prevent a type of pneumonia. (See "Patient information: Pneumonia prevention (Beyond the Basics)".)

People with COPD should also get an annual flu shot before flu season, generally in the late fall or early winter. For patients who get the flu, antiviral medications may be prescribed. (See "Patient information: Influenza prevention (Beyond the Basics)".)

Antibiotics — Antibiotics are of some benefit in people with a bacterial respiratory infection who have worsening COPD symptoms. However, most respiratory infections are caused by viruses, which will not improve with antibiotic treatment. (See "Management of acute exacerbations of chronic obstructive pulmonary disease".)

Continuous use of antibiotics to prevent infection is not currently recommended.

PROGNOSIS

Although chronic obstructive pulmonary disease usually worsens over time, it is difficult to predict how quickly this will occur. A number of factors play a role in the severity of COPD symptoms, including whether you continue to smoke, are underweight, have underlying medical problems, and how your lungs function during exercise. People with COPD who have less severe symptoms, are a healthy weight, and do not smoke tend to live longer.

The BODE index is an example of an index that clinicians use to predict survival and to guide the timing of lung transplantation. It uses a combination of body mass index (BMI), severity of airflow obstruction on spirometry, degree of shortness of breath with exertion, and distance walked in six minutes. (See "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions".)

END OF LIFE DECISIONS IN COPD

Although discussions about death and dying can be uncomfortable for patients, family members, and healthcare providers, the subject is important, especially for people with severe chronic illnesses. Not everyone with COPD will die as a result of their disease. However, discussions about what you want at the end of your life should occur well before you become seriously ill. This is particularly important for people with COPD, who are at risk for being placed on a ventilator (breathing machine) when they are very ill.

Important questions to consider include:

• Who do I want to make medical decisions for me if I cannot communicate?


• Are there specific treatments that I do or do not want at the end of my life?

Certain legal documents, called a healthcare proxy and living will, are used to communicate your preferences. The document you need depends upon where you live. In the United States, state-specific documents can be downloaded from the internet (such as www.caringinfo.org) and do not require a lawyer.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (The Basics)

Patient information: Medicines for chronic obstructive pulmonary disease (COPD) (The Basics)

Patient information: Chronic bronchitis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)

Patient information: Asthma inhaler techniques in adults (Beyond the Basics)

Patient information: Quitting smoking (Beyond the Basics)

Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)

Patient information: Pneumonia prevention (Beyond the Basics)

Patient information: Influenza prevention (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Bullectomy for giant bullae in COPD

Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging

Chronic obstructive pulmonary disease: Risk factors and risk reduction

Management of infection in acute exacerbations of chronic obstructive pulmonary disease

Dynamic hyperinflation in patients with COPD

Lung volume reduction surgery in COPD

Management of acute exacerbations of chronic obstructive pulmonary disease

Management of stable chronic obstructive pulmonary disease

Mechanical ventilation in acute respiratory failure complicating COPD

Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions

Pulmonary rehabilitation in COPD

Use of oxygen in patients with hypercapnia

Nutritional support in advanced lung disease

Lung transplantation: General guidelines for recipient selection



The following organizations also provide reliable health information.

• National Library of Medicine

(www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html, available in Spanish)

• National Heart, Lung, and Blood Institute

(www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html)

• American Lung Association

(www.lungusa.org)

• Alpha-1 Foundation

(www.alphaone.org)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com COPD Forum

(http://copd.about.com/forum)

[1-4]

DIABETES OVERVIEW

Diabetes mellitus is a chronic condition that can lead to complications over time. These complications can include:

• 
  Coronary heart disease, which can lead to a heart attack


• 
  Cerebrovascular disease, which can lead to stroke


• 
  Retinopathy (disease of the eye), which can lead to blindness


• 
  Nephropathy (disease of the kidney), which can lead to kidney failure and the need for dialysis


• 
  Neuropathy (disease of the nerves), which can lead to, among other things, ulceration of the foot requiring amputation (see "Patient information: Diabetic neuropathy (Beyond the Basics)")

Many of these complications produce no symptoms in the early stages, and most can be prevented or minimized with a combination of regular medical care and blood sugar monitoring.

CONTROLLING BLOOD SUGAR IN DIABETES

The long-term complications of diabetes are caused by the effect of high blood sugar levels on blood vessels. Two important studies, the Diabetes Control and Complications Trial (DCCT) in patients with type 1 diabetes and the United Kingdom Prospective Diabetes Study (UKPDS) in patients with type 2 diabetes, found that people with lower blood sugar levels had fewer complications than those with higher values.

Thus, keeping blood sugars close to normal can help prevent the long-term complications of diabetes mellitus. However, there are some risks associated with tight control, particularly an increased risk of hypoglycemia (low blood sugar).

Monitoring blood sugar levels — Monitoring blood sugar with finger sticks at home can indicate how well diabetes is controlled and serves as a guide to adjusting therapy. (See "Patient information: Self-blood glucose monitoring in diabetes mellitus (Beyond the Basics)".) For most people, a target for fasting blood sugar and for blood sugar levels before each meal is 80 to120 mg/dL (4.4 to 6.6 mmol/L); however, these targets may need to be individualized.

A blood test called A1C is also used to monitor blood sugar control; the result provides an average of blood sugar levels during the previous one to three months. An A1C of 7 percent or less is recommended; this corresponds to an average blood sugar of 150 mg/dL (8.3 mmol/L) (table 1).

The A1C target may be somewhat higher in people who are older or who have conditions that increase the risks associated with hypoglycemia. Even small decreases in the A1C lowers the risk of diabetes-related complications to some degree.

The combination of A1C and fingerstick blood sugars provides information about the average and daily blood sugar levels.

Type 1 diabetes — Blood sugar control in type 1 diabetes requires some form of insulin, which can be given with insulin injections or an insulin pump. Most healthcare providers recommend intensive insulin therapy, which requires frequent blood sugar monitoring in addition to frequent injections or use of an insulin pump. (See "Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond the Basics)".)

Intensive insulin therapy increases the risk of low blood sugar, is more expensive than traditional insulin therapy, and requires that the person monitor their blood sugar levels, diet, and activities. Some people who use intensive insulin therapy gain weight, although regular exercise and controlling the amount eaten can prevent weight gain. (See "Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus (Beyond the Basics)".)

Type 2 diabetes — With type 2 diabetes, it is sometimes possible to control blood sugar levels with lifestyle changes, often in combination with oral medications. Insulin injections may be needed when a person is first diagnosed or later in the course of treatment. Most people with type 2 diabetes who take insulin require only one or two injections per day. (See "Patient information: Diabetes mellitus type 2: Insulin treatment (Beyond the Basics)".)

EYE COMPLICATIONS IN DIABETES

Regular eye examinations are essential for detecting eye complications (called retinopathy) at an early stage, when the condition can be monitored and treated to preserve vision.

An eye exam should include dilating the pupils (with medicated eye drops) to completely examine the retina. Unless the pupils are medicated, they contract in response to light, making it impossible to view the entire retina. In some people with retinopathy, photographs of the retina will be taken to monitor the changes. This examination should be performed by a doctor who specializes in the eyes (called an ophthalmologist or optometrist).

The risk of diabetic retinopathy varies with the type and duration of diabetes and with other life events. Thus, the screening guidelines differ from one person to another.

Type 1 diabetes — People with type 1 diabetes should have an eye examination by an ophthalmologist or optometrist beginning five years after they are diagnosed with diabetes, although screening is usually not necessary before puberty. People who have difficulty with their vision or who require glasses or contacts may need to be seen sooner. The frequency of subsequent examinations will depend upon the results of the initial exam. An eye exam is usually recommended every one to two years after the initial examination.

Type 2 diabetes — People with type 2 diabetes should have an eye examination by an ophthalmologist or optometrist when they are first diagnosed with diabetes. The reason for this is that blood sugar levels often increase over a period of several years before the person is diagnosed. Eye complications can develop during this time and often have no symptoms. Having an eye examination soon after diagnosis can help to determine if there are eye complications, the extent or severity of the complications, and if treatment is needed.

The frequency of subsequent exams will depend upon the results of the initial examination. An eye exam is usually recommended every one to two years after the initial examination.

FOOT CARE WITH DIABETES

Diabetes can decrease the blood supply to the feet and damage the nerves that carry sensation. These changes put the feet at risk for developing potentially serious complications such as ulcers. Foot complications are very common among people with diabetes, and may go unnoticed until the condition is severe. (See "Patient information: Diabetic neuropathy (Beyond the Basics)".)

Self exam — People with diabetes should examine their feet every day. It is important to examine all parts of the feet, especially the area between the toes. Look for broken skin, ulcers, blisters, areas of increased warmth or redness, or changes in callus formation; a healthcare provider should be notified if any of these changes are found. (See "Patient information: Foot care in diabetes mellitus (Beyond the Basics)".)

This examination can be a part of the daily bathing or dressing routine. It may be necessary to use a mirror to see the bottoms of the feet clearly. Anyone who is unable to reach their feet or see them completely, even with the help of a mirror, should have someone else (such as a spouse or other family member) assist with the examination.

Clinical exam — During a routine medical visit, the clinician will check the blood flow and sensation in the feet. In people with type 1 diabetes, annual foot examinations should begin five years after diagnosis. In people with type 2 diabetes, annual foot exams should begin at the time of diagnosis.

During a foot examination, the clinician will look for changes such as ulcers, cold feet, thin skin, bluish skin color, and skin breaks associated with athlete's foot. The clinician will also test the sensation in the feet to determine if it is normal or diminished. People with decreased sensation are at risk for foot injuries that can go unnoticed due to lack of pain.

KIDNEY COMPLICATIONS IN DIABETES

Diabetes can alter the normal function of the kidneys. A urine test that measures the amount of protein (albumin) in the urine can determine if diabetes is affecting the kidney's filtering action. Microscopic amounts of albumin in the urine (microalbuminuria) can be an early indicator of diabetes-related kidney complications (called nephropathy). The amount of albumin in the urine can also help the provider determine if nephropathy is worsening. (See "Patient information: Protein in the urine (proteinuria) (Beyond the Basics)".)

Urine screening tests should begin in people with type 1 diabetes about five years after diagnosis, and in people with type 2 diabetes at the time of diagnosis. If the test shows that there is protein in the urine, tight blood sugar and lipid (cholesterol and triglyceride) control are recommended.

A blood pressure medication (an ACE inhibitor or angiotensin receptor blocker [ARB]) is generally recommended if albuminuria does not improve, even if the blood pressure is normal. People with elevated blood pressure and albuminuria are also treated with an ACE inhibitor or ARB. These medications decrease the amount of protein in the urine and can prevent or slow the progression of diabetes-related kidney disease.

HYPERTENSION AND RELATED COMPLICATIONS IN DIABETES

Many people with diabetes have hypertension (high blood pressure). Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye. A healthcare provider can diagnose high blood pressure by measuring blood pressure on a regular basis. (See "Patient information: High blood pressure in adults (Beyond the Basics)".)

A blood pressure reading below 140/90 and perhaps below 130/80 is recommended for most people with diabetes who do not have kidney complications; a lower blood pressure goal (less than 130/80) is recommended for people with diabetes who have kidney disease.

If a person is diagnosed with prehypertension (>120/80), the healthcare provider may recommend weight loss, exercise, decreasing the amount of salt in the diet, quitting smoking, and decreasing alcohol intake. These measures can sometimes reduce blood pressure to normal. (See "Patient information: High blood pressure, diet, and weight (Beyond the Basics)".)

If these measures are not effective or the blood pressure must be lowered quickly, the provider will likely recommend one of several high blood pressure medications. The provider can discuss the pros and cons of each medication and the goals of treatment (see "Patient information: High blood pressure treatment in adults (Beyond the Basics)").

CARDIOVASCULAR COMPLICATIONS IN DIABETES

In addition to lowering blood glucose levels, a number of other measures are important to reduce the risk of cardiovascular (heart and blood vessel) disease.

• 
  Quit smoking.


• 
  Manage high blood pressure with lifestyle modifications and/or medication(s).


• 
  Have a blood test to measure cholesterol and triglyceride levels, and modify the diets if needed. Some people will also need a medication to lower their LDL ("bad cholesterol") or triglycerides.
  
  
  
  If medication is needed, a statin drug should be included whenever possible. The statin drugs have been shown to decrease the future risk of heart attacks, strokes, and death in people with diabetes who are over age 40, even when cholesterol levels are normal.
  
  
  
  The American Diabetes Association recommends that people with diabetes have a low density lipoprotein (LDL) cholesterol level less than 100 mg/dL (2.59 mmol/L). Some studies suggest lowering LDL even further, to 70 to 80 mg/dL (1.81 to 2.07 mmol/L). (See "Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)".)


• 
  Aspirin (81 to 100 mg per day) is recommended for anyone with diabetes who already has or is at increased risk of cardiovascular disease. (See "Patient information: Aspirin and cardiovascular disease (Beyond the Basics)".)

PREGNANCY AND DIABETES

Control of diabetes and its potential complications is especially important for women who are planning to become pregnant, as well as in those who already are pregnant. Controlling blood sugar levels before and during pregnancy decreases the risk of many complications in both the mother and the baby. A separate topic review is available on this subject. (See "Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Type 2 diabetes (The Basics)

Patient information: The ABCs of diabetes (The Basics)

Patient information: Recovery after coronary artery bypass graft surgery (CABG) (The Basics)

Patient information: Diabetic ketoacidosis (The Basics)

Patient information: Hyperosmolar nonketotic coma (The Basics)

Patient information: Gangrene (The Basics)

Patient information: Detached retina (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Care during pregnancy for women with type 1 or 2 diabetes mellitus (Beyond the Basics)

Patient information: Foot care in diabetes mellitus (Beyond the Basics)

Patient information: High blood pressure in adults (Beyond the Basics)

Patient information: High cholesterol and lipids (hyperlipidemia) (Beyond the Basics)

Patient information: High cholesterol treatment options (Beyond the Basics)

Patient information: Self-blood glucose monitoring in diabetes mellitus (Beyond the Basics)

Patient information: Diabetic neuropathy (Beyond the Basics)

Patient information: Diabetes mellitus type 1: Insulin treatment (Beyond the Basics)

Patient information: Hypoglycemia (low blood sugar) in diabetes mellitus (Beyond the Basics)

Patient information: Diabetes mellitus type 2: Insulin treatment (Beyond the Basics)

Patient information: Protein in the urine (proteinuria) (Beyond the Basics)

Patient information: High blood pressure, diet, and weight (Beyond the Basics)

Patient information: High blood pressure treatment in adults (Beyond the Basics)

Patient information: Aspirin and cardiovascular disease (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical presentation and diagnosis of diabetes mellitus in adults

Estimation of blood glucose control in diabetes mellitus

Glycemic control and vascular complications in type 1 diabetes mellitus

Glycemic control and vascular complications in type 2 diabetes mellitus

Medical management of type 1 and type 2 diabetes mellitus in pregnant women

Insulin therapy in adults with type 1 diabetes mellitus

Insulin therapy in type 2 diabetes mellitus

Management of diabetes mellitus in hospitalized patients

Management of persistent hyperglycemia in type 2 diabetes mellitus

Overview of medical care in adults with diabetes mellitus

Screening for diabetes mellitus

Treatment of hypertension in patients with diabetes mellitus

Treatment of type 2 diabetes mellitus in the elderly patient



The following organizations also provide reliable health information.

• 
  National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

• 
  National Institute of Diabetes and Digestive and Kidney Diseases

(www.niddk.nih.gov/)

• 
  American Diabetes Association (ADA)

(800)-DIABETES (800-342-2383)

(www.diabetes.org)

• 
  The Hormone Foundation

(www.hormone.org/public/diabetes.cfm, available in English and Spanish)

[1-6]

DIARRHEA OVERVIEW

Diarrhea is defined as three or more loose or watery stools per day. Nearly everyone will have an episode of diarrhea at some point during their life, with the average adult experiencing it four times per year. Although most cases of diarrhea resolve within a few days without treatment, it's important to know when to seek help.

This topic review discusses the causes and treatments of sudden onset (acute) diarrhea in adults in developed countries. A discussion of acute diarrhea in developing countries and returning travelers is not included here. Diarrhea that lasts for more than 14 days (called chronic diarrhea) and acute diarrhea in children are discussed in separate topic reviews. (See "Patient information: Chronic diarrhea in adults (Beyond the Basics)" and "Patient information: Acute diarrhea in children (Beyond the Basics)".)

A topic review that discusses antibiotic-associated diarrhea is also available. (See "Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)".)

DIARRHEA CAUSES

Diarrhea can be caused by infections or a variety of other factors. The cause of diarrhea is not identified in most people, especially those who improve without treatment.

Diarrhea caused by infections usually results from eating or drinking contaminated food or water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and resolve within three to seven days. (See "Patient information: Food poisoning (food-borne illness) (Beyond the Basics)".)

Diarrhea not related to an infection can occur as a side effect of antibiotics or other drugs, food allergies, gastrointestinal diseases such as inflammatory bowel disease, and other diseases. In addition, there are many less common causes of diarrhea. A summary of the various common causes of diarrhea is available in the table (table 1).

DIARRHEA SYMPTOMS

A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this situation, a significant amount of water and salts can be lost, seriously increasing the risk of dehydration. Diarrhea may be accompanied by fever (temperature greater than 100.4ºF or 38ºC), abdominal pain, or cramping.

DIARRHEA HOME CARE

Drink adequate fluids — If you have mild to moderate diarrhea, you can usually be treated at home by drinking extra fluids. The fluids should contain water, salt, and sugar. The fluids used for sweat replacement (eg, Gatorade) are not optimal, although they may be sufficient for a person with diarrhea who is not dehydrated and is otherwise healthy. Diluted fruit juices and flavored soft drinks along with salted crackers and broths or soups may also be acceptable.

One way to judge hydration is by looking at the color of your urine and monitoring how frequently you urinate. If you urinate infrequently or have urine that is dark yellow, you should drink more fluids. Normally, urine should be light yellow to nearly colorless. If you are well hydrated, you normally pass urine every three to five hours.

If you become dehydrated and are unable to take fluids by mouth, a rehydration solution can be given into a vein (intravenous fluids) in a healthcare provider's office or in the emergency department.

Diet — There is no particular food or group of foods that is best while you have diarrhea. However, adequate nutrition is important during an episode of acute diarrhea. If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oats) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.

Antidiarrheal medications — Medications to reduce diarrhea are available, and are safe if there is no fever (temperature greater than 100.4ºF or 38ºC) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements.

• Loperamide (Imodium®) is available without a prescription; the dose is two tablets (4 mg) initially, then 1 tablet (2 mg) after each unformed stool. No more than 16 mg is recommended per day.


• Diphenoxylate (Lomotil®) is a prescription medication used to treat diarrhea; its benefit is similar to loperamide, although it can be associated with more bothersome side effects.


• Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®) has also been used for treatment of acute diarrhea, although it is not as effective as loperamide. Bismuth subsalicylate may be recommended in certain situations, such as if you have fever and bloody diarrhea. However, women who are pregnant should not take bismuth subsalicylate. The dose of bismuth subsalicylate is 30 mL or two tablets every 30 minutes for up to eight doses.

Antibiotics — Antibiotics are not needed in most cases of acute diarrhea, and they can actually worsen diarrhea or cause further complications if used inappropriately. Antibiotics may be recommended in certain situations, such as if you have the following signs or symptoms:

• Moderate to severe traveler's diarrhea


• More than eight loose stools per day, dehydration, symptoms that continue for more than one week, a weakened immune system, and in those who require hospitalization

However, the decision to use antibiotics must be made carefully after discussing the potential risks and benefits with a healthcare provider who is familiar with the situation.

Preventing spread — Adults with diarrhea should be cautious to avoid spreading infection to family, friends, and co-workers. You are considered infectious for as long as diarrhea continues. Microorganisms causing diarrhea are spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.

Hand washing — Hand washing is an effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antibacterial soap and rubbed together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse the hands thoroughly and dry with a single use towel.

If a sink is not available, alcohol-based hand rubs are a good alternative for disinfecting hands. Spread the hand rub over the entire surface of hands, fingers, and wrists until dry. Hand rubs may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available and the hands are dirty, wash them with soap and water.

Clean the hands after changing a diaper, before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing the nose or sneezing.

DIARRHEA PREVENTION

Food safety — The following precautions have been recommended for all consumers by the Food Safety and Inspection Services (www.fsis.usda.gov) and the Centers for Disease Control and Prevention.

• Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.


• Wash raw fruits and vegetables thoroughly before eating.


• Keep the refrigerator temperature at 40ºF (4.4ºC) or lower; the freezer at 0ºF (-17.8ºC) or lower.


• Use precooked, perishable, or ready-to-eat food as soon as possible.


• Keep raw meat, fish, and poultry separate from other food.


• Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.


• Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160ºF (71ºC); chicken 170ºF (77ºC); turkey 180ºF (82ºC); pork 145ºF (63ºC) with a three minute rest time.


• Seafood should be cooked thoroughly to minimize the risk of food poisoning. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.


• Cook chicken eggs thoroughly, until the yolk is firm.


• Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90ºF/32ºC).

Food safety for pregnant women or those with a weakened immune system — The following additional recommendations apply to pregnant women and those who have a weakened immune system:

• Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.


• Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.


• Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.


• Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.


• Do not eat refrigerated pates or meat spreads. Canned or shelf-stable products may be eaten.


• Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.

Travelers' diarrhea prevention — Recommendations to prevent travelers' diarrhea are available separately. (See "Patient information: General travel advice (Beyond the Basics)".)

WHEN TO SEEK HELP FOR DIARRHEA

If your diarrhea is not severe, you do not always need to be seen by a doctor, especially if the diarrhea begins to improve within 48 hours. Self-care measures for this situation are discussed above (see 'Diarrhea home care' above).

However, if you have one or more of the following signs or symptoms, you should be evaluated by a healthcare provider:

• Profuse watery diarrhea with signs of dehydration. Early features of dehydration include sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.


• Many small stools containing blood and mucus


• Bloody or black diarrhea


• Temperature ≥38.5ºC (101.3ºF)


• Passage of ≥6 unformed stools per 24 hours or illness that lasts more than 48 hours


• Severe abdominal pain/painful passage of stool

In addition, if you have persistent diarrhea following antibiotics, are older than 69 years, have other medical illness or a weakened immune system, you should also consult your healthcare provider.

SUMMARY

• Acute diarrhea is defined as three or more loose or watery stools per day.


• Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days.


• A person may have mild to severe diarrhea. Some people with diarrhea also have fever (temperature greater than 100.4ºF or 38ºC), abdominal pain, or cramping.


• People with mild diarrhea do not usually need to go to the doctor, especially if the diarrhea begins to improve within 48 hours. If you develop any of the following, you should call your doctor or nurse immediately:

• Profuse watery diarrhea with sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.


• Passage of many small stools containing blood and mucus


• Bloody or black diarrhea


• Temperature ≥38.5ºC (101.3ºF)


• Passing 6 or more watery stools per 24 hours or illness that lasts more than 48 hours


• Severe abdominal pain

• In addition, if you have persistent diarrhea after finishing antibiotics, are older than 69, or have other medical illness or a weakened immune system, you should also consult your doctor or nurse.


• The most important treatment for diarrhea is to drink fluids that contain water, salt, and sugar. Sports drinks (eg, Gatorade) may be acceptable if you are not dehydrated and are otherwise healthy. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may also be acceptable.


• If you have dark yellow colored urine or do not pass urine frequently, you should drink more fluids. The urine should normally be light yellow to clear colored.


• Medications to reduce diarrhea are available without a prescription, and are safe if there is no fever (temperature greater than 100.4ºF or 38ºC) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements. Common medications include loperamide (Imodium®), diphenoxylate (Lomotil®), and bismuth subsalicylate (Pepto-Bismol® or Kaopectate®).


• If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.


• Antibiotics are not needed for most people with diarrhea.


• If you have diarrhea, be careful to avoid spreading the infection to family, friends, and co-workers. You are contagious for as long as diarrhea continues. Infections are usually spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Diarrhea in adults (The Basics)

Patient information: Diarrhea in children (The Basics)

Patient information: Food poisoning (The Basics)

Patient information: Lactose intolerance (The Basics)

Patient information: Antibiotic-associated diarrhea (C. difficile infection) (The Basics)

Patient information: Managing loss of appetite and weight loss with cancer (The Basics)

Patient information: Dehydration (The Basics)

Patient information: Ischemic bowel disease (The Basics)

Patient information: Cryptosporidiosis (The Basics)

Patient information: Salmonellosis (Salmonella) (The Basics)

Patient information: Travelers’ diarrhea (The Basics)

Patient information: E. coli (The Basics)

Patient information: Listeria (The Basics)

Patient information: Campylobacter infection (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Chronic diarrhea in adults (Beyond the Basics)

Patient information: Acute diarrhea in children (Beyond the Basics)

Patient information: Antibiotic-associated diarrhea caused by Clostridium difficile (Beyond the Basics)

Patient information: Food poisoning (food-borne illness) (Beyond the Basics)

Patient information: General travel advice (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Approach to the adult with acute diarrhea in developed countries

Clinical manifestations, diagnosis, and treatment of Campylobacter infection

Clostridium difficile in adults: Clinical manifestations and diagnosis

Clinical manifestations and diagnosis of Shigella infection

Clinical manifestations, diagnosis and treatment of enterohemorrhagic Escherichia coli (EHEC) infection

Clinical presentation and diagnosis of rotavirus infection

Epidemiology, clinical manifestations, and diagnosis of cryptosporidiosis

Pathogenic Escherichia coli

Differential diagnosis of microbial foodborne disease

Epidemiology and causes of acute diarrhea in developed countries

Epidemiology of viral gastroenteritis in adults

Epidemiology, clinical manifestations and diagnosis of norovirus and related viruses

Overview of Vibrio cholerae infection

Management of acute viral gastroenteritis in adults

 

The following organizations also provide reliable health information.

• National Library of Medicine
  
  
  
  (www.nlm.nih.gov/medlineplus/healthtopics.html)


• National Institute of Digestive and Diabetes and Kidney Diseases
  
  
  
  (http://digestive.niddk.nih.gov/ddiseases/pubs/diarrhea/index.htm)


• Center for Disease Control and Prevention
  
  
  
  (www.cdc.gov)


• American College of Gastroenterology
  
  
  
  (www.acg.gi.org/patients/gihealth/diarrheal.asp)

[1-4]

EDEMA OVERVIEW

Edema is the medical term for swelling caused by a collection of fluid in the small spaces that surround the body's tissues and organs. Edema can occur nearly anywhere in the body. Some of the most common sites are:

• 
  The lower legs or hands (also called peripheral edema)


• 
  Abdomen (also called ascites)


• 
  Chest (called pulmonary edema if in the lungs and pleural effusion if in the space surrounding the lungs)

Ascites and peripheral edema can be uncomfortable and can be a sign of a more serious condition. Pulmonary edema, which can be life-threatening, is a symptom of heart failure and is discussed in more detail separately. (See "Patient information: Heart failure (Beyond the Basics)".)

EDEMA SYMPTOMS

Symptoms of edema depend upon the cause but may include:

• 
  Swelling or puffiness of the skin, causing it to appear stretched and shiny. This typically is worse in the areas of the body that are closest to the ground (because of gravity). Therefore, edema is generally the worst in the lower legs (called peripheral edema) after walking about, standing, sitting in a chair for a period of time, or at the end of the day. It accumulates in the lower back (called sacral edema) after being in bed for a long period. Pushing on the swollen area for a few seconds will leave a dimple in the skin (picture 1).


• 
  Increased size of the abdomen (with ascites).


• 
  Shortness of breath (with edema in the chest).

CONDITIONS ASSOCIATED WITH EDEMA

A number of different problems can cause edema.

Chronic venous disease — A common cause of edema in the lower legs is chronic venous disease, a condition in which the veins in the legs cannot pump enough blood back up to the heart because the valves in the veins are damaged. This can lead to fluid collecting in the lower legs, thinning of the skin, and, in some cases, development of skin sores (ulcers) (figure 1). (See "Patient information: Chronic venous disease (Beyond the Basics)".)

Edema can also develop as a result of a blood clot in the deep veins of the lower leg (called deep vein thrombosis [DVT]). In this case, the edema is mostly limited to the feet or ankles and usually affects only one side (the left or right); other conditions that cause edema usually cause swelling of both legs. (See "Patient information: Deep vein thrombosis (DVT) (Beyond the Basics)".)

Pregnancy — Pregnant women retain extra fluid. Swelling commonly develops in the hands, feet, and face, especially near the end of a normal pregnancy. Swelling without other symptoms and findings is not usually a sign that a complication, such as preeclampsia (sometimes called toxemia), has developed. (See "Patient information: Preeclampsia (Beyond the Basics)".)

Monthly menstrual periods — Edema in women that occurs in a cyclic pattern (usually once per month) can be the result of hormonal changes related to the menstrual cycle. This type of edema is common but does not require treatment because it resolves on its own.

Drugs — Edema can be a side effect of a variety of medications, including some oral diabetes medications, high blood pressure medications, non-prescription pain relievers (such as ibuprofen), and estrogens.