About anesthesia in IHD patient

1. ISCHEMIC HEART DISEASE IN NON CARDIAC
SURGERIES- ANESTHETIC APPROACH
MODERATOR : DR UMA ASSOCIATE PROFESSOR
DR.K.P. Kameshwaran IIIYEAR PG
KIMS
ANESTHESIA DEPARTMENT

2. OBJECTIVES
• To define ischemic heart disease and its pathogenesis.
• To know the perioperative concerns in patient with IHD.
• To know the stepwise approach to patient with IHD
• To know the anaesthetic management in patient with ischemic heart
disease for non cardiac surgery.

3. Ischemic heart disease
• Inadequate supply of blood and oxygen to a portion of myocardium
• Cause- Atherosclerotic disease of epicardial coronary arteries.
• Perioperative myocardial infarction occurs in up to 6.2% of surgeries
• (i)Acute coronary syndrome and (ii)prolonged myocardial oxygen
supply-demand imbalance in the presence of stable CAD
• The major determinants of myocardial oxygen consumption are
myocardial contractility and ventricular wall tension

4. Patients with ischemic heart disease can have
• Chronic stable angina
• Acute coronary syndrome.
• ST elevation myocardial infarction (STEMI) /
• Non–ST elevation myocardial infarction (NSTEMI)

7. CARDIOVASCULAR COMPLICATIONS –
• perioperative MI
• pulmonary edema
• systolic and diastolic heart failure
• arrhythmias
• stroke and thromboembolism.

8. RISK FACTORS
• Male gender
• Increasing age
• Hypercholesterolemia
• Hypertension
• Cigarette Smoking
• Diabetes mellitus
• Obesity
• Sedentary lifestyle
• Genetic factors
• Family history

9. The goals of preoperative evaluation are to
(1) ascertain whether the patient has previously undiagnosed
significant IHD
(2) characterize any known IHD with respect to severity, functional
limitations, therapy, and prior investigations
(3) determine whether additional preoperative specialized testing or
consultations are warranted
(4) identity opportunities for reducing perioperative risk related to IHD
(5) How urgent is surgery is whether emergency ,urgent ,time-sensitive
or elective

10. PRE- OP EVALUATION
• Types of IHD,
• Prior myocardial infarction duration,
• Hypertension
• Congestive heart failure
• Obesity
• Respiratory disease
• Smoking
• Obstructive sleep apnea

11. investigating or optimizing
• consultations,
• biomarkers,
• stress testing either exercise or pharmacologic
• coronary angiography
• coronary revascularization
• medical therapy
• Invasive coronary angiography is the gold standard for diagnosing IHD

12. ecg

13. Lv function

14. Stepwise approach
• Is there clinical need for emergency surgery?
• Are there active cardiac conditions ?
• Does the patient have clinical risk factors?
• Does the planned surgery have cardiac risk?
• Does the pt have good functional capacity without symptoms?

17. Functional status /capacity assessment
• Mets
• DASI Scoring
• CPET

18. METS --Functional capacity is typically quantified in using the metabolic equivalent of task (MET), where one MET
is approximately the rate of energy consumption at rest (3.5 mL/kg/min) in adult 70 kg male of age 40 years.

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21. Perioperative and post operativeMonitoring
• ECG, Pulse oximetry, Temperature, ETCO2,
• Cardiovascular monitors
Intraarterial blood pressure
Central venous catheter
Pulmonary catheter
TEE
• Others- urine output, EEG, ABG

22. Anaesthesia and myocardial oxygen balance
• diastolic pressure time index (DPTI)
• tension time index (TTI),
• endocardial viability ratio (EVR

23. • Halogenated anaesthetic agents activate ATP sensitive potassium
channels and lower intracellular calcium
• Isoflurane – coronary steal phenomenon
negative inotropy ischaemic preconditioning

24. INDUCTION OF ANESTHESIA
• ETOMIDATE is the DOC
• Ketamine is not preferred unless pt in shock because the associated
increase in heart rate and blood pressure transiently increases
myocardial oxygen requirements.
• Muscle relaxant ===> by administration of Succinylcholine or NDMR for
intubation, Short duration of direct laryngoscopy is useful in
minimizing the duration of the circulatory changes associated
with tracheal intubation.

25. INDUCTION OF ANESTHESIA
• Laryngo tracheal lidocaine,
• IV lidocaine,
• Esmolol
• Fentanyl
• Dexmedetomidine have all to
be useful for blunting the increase in heart rate evoked by
tracheal intubation.

26. MAINTAINENCE OF ANESTHESIA
• Volatile anesthetics may be beneficial in patients with
IHD↓ myocardial oxygen requirements ↓ in BP
===> ↓ coronary perfusion pressure.
• Nitrous oxide ===> may have harmful effects
(↑in PVR , ↑ diastolic dysfunction)

27. MAINTAINENCE OF ANESTHESIA
• Regional anesthesia
Excellent pain control,
↓ incidence of DVT
• Muscle relaxants with minimal or no effect on HR and
systemic BP pressure (vecuronium , rocuronium,
cisatracurium) are attractive choices for patients with IHD.

28. REVERSAL
• Reversal of neuromuscular blockade
(anticholinesterase + anticholinergic ===> safe in patients with
IHD (glycopyrrolate ===> is preferred )
• Extubation should be smooth by avoiding sympathetic stimulation.

29. POSTOPERATIVE PERIOD
• Avoiding of shivering ,
(leading to abrupt and dramatic increases in myocardial
oxygen requirements)
• Pain, hypoxemia, hypercarbia, sepsis, hemorrhage ===>
increased myocardial oxygen demand ===> oxygen
supply/demand imbalance ===> precipitate myocardial
ischemia, infarction, or death.

30. POSTOP PERIOD
• Prevention of hypovolemia is necessary postoperatively,
(with adequate intravascular volume & adequate Hb
concentration )
• Continuous ECG monitoring (post-op myocardial ischemia is
often silent)

31. Take home message…
• All pts with IHD should have an assessment of risk perioperative
cardiac events.
• Identification of risk factors
• Active cardiac conditions , clinical risk factors, surgical risk factors and
functional status are the major outcome determinants in IHD pts
undergoing surgery.
• Perioperative goals in patient with IHD- maintaining a favourable
myocardial supply and demand relationship.

32. ..
Thank you