Problem

Tim goes to his family physician complaining of worsening angina, shortness of breath, and extreme fatigue. Tim is 5'11", 240 lbs, and 68 years old. He has a history of smoking (one pack a day for 40 years), and is on the verge of Type II diabetes. Tim has been previously diagnosed with atherosclerosis, and has had bypass surgery to correct 2 blocked coronary arteries. A year ago, Tim had a heart attack and spent a couple of months in the hospital, during which he quit smoking.

Tim is retired, and leads a virtually sedentary lifestyle. He goes for a walk with his wife one or two times a week when she drags him out, but lately he's been too tired even to do that. He tries to watch what he eats - he avoids sweets most of the time, but still consumes a relatively high fat diet and has at least one beer every evening. He's a bit concerned about his condition, but apart from the occasional chest pain and fatigue, claims that he feels "just fine".

Tim's vitals at the doctor's office are as follows:

HR 90 bpm; slightly irregular

BP 140/80
Respirations - slight tachypnea, shallow
His last bloodwork revealed the following:
Total cholesterol - 240 mg/dL
HDL - 31 mg/dL
LDL - 140 mg/dL
Fasting glucose - 100 mg/dL
Slightly elevated CRP
Slight hypernatremia

Further imaging has shown blockage in a new coronary vessel, and Tim wants to have another bypass surgery (this would mean he would have 3 total coronary arteries bypassed).

1. Is Tim a good candidate for bypass surgery? Why or why not? Give 3 reasons to support your answer.

2. Tim could also make lifestyle modifications - but he has not yet committed to making any major changes. Describe how you could convince him to make those necessary changes to his lifestyle.

3. Do you think Tim's health insurance should pay for this bypass surgery? Why or why not?