This document discusses ischemic heart disease and its anesthetic management. It begins with defining ischemic heart disease and its causes. It then discusses the perioperative concerns and management for patients undergoing non-cardiac surgery who have ischemic heart disease. This includes preoperative evaluation and testing, intraoperative goals of maintaining a favorable myocardial supply and demand relationship, and anesthetic techniques including general or regional anesthesia to minimize cardiac risk.

1. Ischemic heart Disease
and Anesthetic
Management
Presenter: Dr Krishna Dhakal
Department Of Anesthesiology , SGNHC 16/26/2019

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 perioperative management in patient
with Ischemic Heart Disease for non cardiac
surgery
Department Of Anesthesiology , SGNHC 26/26/2019

3. Ischemic Heart Disease
• A disease - inadequate supply of blood and oxygen
to a portion of myocardium of coronary arteries
• Also known as- Coronary artery disease
• Most common -atherosclerotic disease of epicardial
coronary arteries
• Regional reduction in myocardial blood flow and
inadequate supplied by involved coronary artery
Harrison’s principle of internal medicine-20th edition
Department Of Anesthesiology , SGNHC 36/26/2019

4. Ischemic Heart Disease
1. Stable angina
2. Acute coronary syndrome -Unstable angina ,
Myocardial infarction- NSTEMI and STEMI
3. Sudden cardiac death
Harrison’s principle of internal medicine-20th edition
Department Of Anesthesiology , SGNHC 46/26/2019

5. Background
• Proportion of CAD in Nepal-0.56% (Tikapur) -
15.12% (Birgunj) 1
• Vaidya A et al have revealed the prevalence of
coronary artery disease to be 5.78 2
Department Of Anesthesiology , SGNHC 5
1. Nepalese Heart Journal Vol.8(1) 2011 pp.23-26
2 . Vaidya A, Pokharel PK, Nagesh S, Karki P, Kumar S, MajhiS. Prevalence of coronary heart disease
in the urban adult males of eastern Nepal: a population-based analytical cross-sectional study.
Indian Heart J. 2009 Jul-Aug;61(4):341-7
6/26/2019

6. Risk Factors For Ischemic Heart Disease
Department Of Anesthesiology , SGNHC 66/26/2019

7. Myocardial oxygen delivery and
demand
Department Of Anesthesiology , SGNHC 76/26/2019

8. Myocardial oxygen delivery and
demand
Three major determinants of myocardial oxygen
Demand
• Myocardial wall tension( PR/2T)
• Contractility
• HR
Department Of Anesthesiology , SGNHC 86/26/2019

9. Determinants of 02 supply
• coronary blood flow * arterial 02 content
Coronary blood flow
• Diastolic arterial pressure
• LVEDP
• Patency of coronary arteries
• Coronary vascular tone
Arterial 02 content
Ca02= 1.34*Hb *Sa02+(0.0031*Pa02)
Department Of Anesthesiology , SGNHC 96/26/2019

10. Coronary Anatomy and Blood flow
6/26/2019 Department Of Anesthesiology , SGNHC 10

11. Coronary Anatomy and Blood flow
• Distribute blood flow from
epicardium to different
regions of myocardium -
endocardium
• Small arteries and arterioles-
Primary sites of vascular
resistance- also primary site of
regulation of blood flow
Department Of Anesthesiology , SGNHC 116/26/2019

12. Coronary Anatomy and Blood flow
• Coronary Blood Flow –
maintain due to change in
Arterial resistance and
Coronary perfusion pressure
• Alterations in the tone of the
small intramyocardial arterioles
regulate diastolic vascular
resistance- matching of oxygen
supply with MV⋅O2 over a wide
range of perfusion pressures
Department Of Anesthesiology , SGNHC 126/26/2019

13. Pathogenesis
• Epicardial and myocardial coronary stenosis -
progressive vasodilation of resistance vessels allows
preservation of basal flow-at the cost of reduced
reserve
• Coronary perfusion  below 40 mm Hg –
autoregulation of subendocardial coronary flow lost
• MV.O2 increase above available reserve-signs ,
symptoms and metabolic evidence of ischemia
develop
Ford TJ, et al. Heart 2017
Department Of Anesthesiology , SGNHC 136/26/2019

14. 6/26/2019 Department Of Anesthesiology , SGNHC 14

15. General approach of management of
IHD
• Correction of risk factors
• Modification of lifestyle to reduce stress response
and improve exercise tolerance
• Correction of complicating medical conditions that
can exacerbate ischemia (HTN, anemia, hypoxemia,
hyperthyroidism, fever, adverse drug effect)
• Pharmacological manipulation of myocardial
oxygen supply-demand
• Anticoagulation
• Corrections of coronary lesions by PCI /CABG
Department Of Anesthesiology , SGNHC 166/26/2019

16. GOALS OF PRE-OPERATIVE EVALUATION
• Evaluate a patient’s current medical status,
• Provide clinical risk profiling,
• Decide on further testing,
• Treat the modifiable risk factors
• Plan management of cardiac illness during the
peri-operative period.
Department Of Anesthesiology , SGNHC 176/26/2019

17. History
• Typical angina pectoris
• Chest discomfort –heaviness ,
pressure ,squeezing
• Arise in or radiate back,
interscapular region root of neck,
jaw teeth
• Levine’s sign
• Dyspnea
• Poor exercise tolerance
• Syncope
Department Of Anesthesiology , SGNHC 186/26/2019

18. Pre-operative Evaluation
• Types of IHD , Prior myocardial infarction duration
of IHD , current status , and the treatment patient
is on should be sought.
• HTN
• CHF
• Obesity
• Respiratory disease, smoking and obstructive sleep
apnoea syndromes
Department Of Anesthesiology , SGNHC 196/26/2019

19. Pre-operative Evaluation
• Cerebrovascular disease(Stroke)
• DM
• Renal disease
• Hyperlipidemia
• Coagulation disorders
• Concurrent medication- herbal medication
• Psychotropic medication- lithium, SSRI, MAO inhibitors
• Personal Hx- cigarette smoker ,alcoholic
• Family history
Department Of Anesthesiology , SGNHC 206/26/2019

20. Physical Examination
• Often normal
• Signs of RV and LV dysfunction
• Carotid bruit
• Orthostatic hypotension- attenuated autonomic
dysfunction
• Raised JVP
• Pedal Edema
• Auscultation -S3
Department Of Anesthesiology , SGNHC 216/26/2019

21. Investigations
• Cardiac enzymes – CPK MB, cardiac specific
troponins
• ECG- baseline normal in 25-75% , ST and T wave
changes , f/o arrhythmia
Specialized Testing
• Exercise electrocardiography
• Myocardial perfusion scans
• Echocardiography
• Coronary angiography
Department Of Anesthesiology , SGNHC 226/26/2019

22. Non-invasive Cardiac Stress Testing
ESC/ESA and the AHA/ACC 2014 guidelines propose
preoperative stress testing if all the following criteria
met:
• Surgery is elective.
• Patient has poor functional capacity limited by angina
or shortness of breath (, 4 Metabolic equivalents
(METs), or with unknown functional capacity).
• Patient has an elevated perioperative risk of major
adverse coronary events.
• Testing will impact decision making for perioperative
care.
Department Of Anesthesiology , SGNHC 236/26/2019

23. Summary For Recommendation for
supplement Preop Evaluaion
Department Of Anesthesiology , SGNHC 246/26/2019

24. Stepwise approach to patient with IHD
1. IS THERE CLINICAL NEED FOR EMERGENCY
SURGERY?
2. ARE THERE ACTIVE CARDIAC CONDITIONS?
3. DOES THE PATIENT HAVE CLINICAL RISK FACTORS?
4. DOES THE PLANNED SURGERY HAVE CARDIAC
RISK(SURGICAL RISK)?
5. DOES THE PATIENT HAVE GOOD FUNCTIONAL
CAPACITY WITHOUT SYMPTOMS?
Department Of Anesthesiology , SGNHC 256/26/2019

25. STEP 1: IS THERE CLINICAL NEED FOR
EMERGENCY NONCARDIAC SURGERY?
• Emergency surgery
• Pt who have suspected Coronary artery disease ,HF
or severe valvular heart disese
• No sufficient time for an extensive evaluation of
the severity of a patient’s cardiovascular problem
• Benefit of proceeding with surgery outweighs the
risk of waiting to perform additional testing
• Proceed to Surgery (Class I recommendation)
Department Of Anesthesiology , SGNHC 266/26/2019

26. Step 2 :Does the patient has active cardiac
condition??
Recent MI
• A recent MI increases the risk of perioperative MI
• Retrospective study - risk of reinfarction decreased
from 32.8% when surgery occurred within 0-30
days of MI compared with 5.9% when surgery
occurred 91-180 days post-MI.
• AHA- delay elective surgery for at least 60 days
post-MI where possible to mitigate risk
Department Of Anesthesiology , SGNHC 276/26/2019

27. Does the patient has active cardiac
condition??
Coronary Revascularisation
• Similar to the indications outside of the
perioperative setting.
• No benefit- for preoperative prophylactic
revascularisation in patients with stable or
asymptomatic coronary artery disease except for
ACS
• Revascularisation with either PCI or surgery - no
improvement in outcomes unless with a strong
indication for cardiac surgery-as left main stem
disease or its equivalent.
Department Of Anesthesiology , SGNHC 286/26/2019

28. Does the patient has active cardiac
condition??
Indications for pre-operative coronary artery
revascularisation
1. Acceptable coronary revascularisation risk and viable
myocardium with left main coronary artery stenosis
2. Three vessel coronary artery disease with left
ventricular dysfunction
3. Left main equivalent (high-grade block in the left
anterior descending artery and circumflex artery)
4. Intractable coronary ischaemia despite maximal
medical therapy.
Department Of Anesthesiology , SGNHC 296/26/2019

29. Does the patient has active cardiac
condition??
Recent Percutaneous Coronary Intervention (PCI)
• Subsequent to PCI- a known risk of in-stent
thrombosis -decreases with time
• In-stent thrombosis - result in myocardial ischaemia
- associated with a high mortality.
• Dual antiplatelet agents for the highest-risk period
• Dual antiplatelet therapy -the susceptibility to
bleeding perioperatively.
Department Of Anesthesiology , SGNHC 306/26/2019

30. Does the patient has active cardiac
condition??
Recent Percutaneous Coronary Intervention (PCI)
• 2014 AHA/ACC guidelines recommends- elective
surgery delayed
• Urgent or emergency surgery have a
multidisciplinary discussion regarding the risk and
benefit of continuing or ceasing antiplatelet agents
preoperatively.
• Aspirin should be continued where possible.
Department Of Anesthesiology , SGNHC 316/26/2019

31. Department Of Anesthesiology , SGNHC 326/26/2019

32. 6/26/2019 Department Of Anesthesiology , SGNHC 33

33. STEP 3: DOES THE PATIENT HAVE CLINICAL
RISK FACTORS?
Risk factors used in risk prediction
• Revised Cardiac Risk Index(lee’s)
• American college of Physician risk calculation
Department Of Anesthesiology , SGNHC 346/26/2019

34. Lee’s Revised cardiac risk index (RCRI)
Department Of Anesthesiology , SGNHC 356/26/2019

35. Revised cardiac risk index (RCRI)
Department Of Anesthesiology , SGNHC 366/26/2019

36. American college of Physician risk calculation
Department Of Anesthesiology , SGNHC 376/26/2019

37. STEP 4: DOES THE PLANNED SURGERY HAVE
A CARDIAC RISK?
2014 ACC/AHA Guidelines on non-cardiac surgery:
cardiovascular assessment and management
Surgical risk estimate according to type of surgery or
intervention,
Department Of Anesthesiology , SGNHC 386/26/2019

38. Department Of Anesthesiology , SGNHC 396/26/2019

39. Management based on Risk
• Low-risk patients—Patients whose estimated risk
of death is less than 1% are labeled as being low
risk and require no additional cardiovascular
testing.
• Higher-risk patients—Patients whose risk of death
is 1% or higher may require additional
cardiovascular evaluation.
Department Of Anesthesiology , SGNHC 406/26/2019

40. 6/26/2019 Department Of Anesthesiology , SGNHC 41

41. STEP 5: DOES THE PATIENT HAVE GOOD
FUNCTIONAL CAPACITY WITHOUT
SYMPTOMS?
Cardiac functional status
• Important indicator of poor functional status and
an increased risk of postoperative cardiopulmonary
complications after major noncardiacsurgery -
inability to climb two flights of stairs or walk four
blocks.
Department Of Anesthesiology , SGNHC 426/26/2019

42. STEP 5: DOES THE PATIENT HAVE GOOD
FUNCTIONAL CAPACITY WITHOUT SYMPTOMS?
• Functional status - expressed in metabolic equivalents (1
MET is defined as 3.5 mL O2uptake/kgper min, which is the
resting oxygen uptake in a sitting position).
Department Of Anesthesiology , SGNHC 436/26/2019

43. Duke Activity Status Index
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44. Department Of Anesthesiology , SGNHC 456/26/2019

45. Department Of Anesthesiology , SGNHC 466/26/2019

46. Medication Considerations
• Beta-Blockers
• Aspirin
• Angiotensin-converting enzyme inhibitors (ACEis)
and angiotensin-receptor blockers (ARBs)
• Statins
Department Of Anesthesiology , SGNHC 476/26/2019

47. Intra operative Goals and consideration
• Maintaining a favorable myocardial supply and
demand relationship
Perioperatve Myocardial Ischaemia in Non-cardiac Surgery (ATOTW 375 -
2018) Department Of Anesthesiology , SGNHC 486/26/2019

48. Anesthetic Technique
• Aim to keep myocardial oxygen supply greater than
demand and avoid ischemia
Choice Of Anesthesia
• General or regional anaesthesia - chosen alone or
in combination as parts of balanced technique
depending on surgery and patient requirements.
Department Of Anesthesiology , SGNHC 496/26/2019

49. Anesthetic Technique
• General anaesthesia -maintenance of haemodynamic
stability with attenuation of the haemodynamic
responses to intubation and surgical stimulation
• Premedication -Anxiolytics – benzodiazepines
• Induction - etomidate preferred , Propofol alternative,
Ketamine -avoided
• Attenuation of laryngoscopy and intubation- opioids,
lidocaine or induction agents
• Maintenance-either by volatile agents such as
isoflurane, sevoflurane, desflurane or TIVA, analgesics
(opioids) and using muscle relaxants.
Department Of Anesthesiology , SGNHC 506/26/2019

50. Anesthetic Technique
Monitoring
• ASA standard monitors- ECG, pulse oximetry,
temperature, ETC02
Cardiovascular monitors
• Intrarterial Blood pressure
• Central venous catheter
• Pulmonary artery catheter
• TEE
Department Of Anesthesiology , SGNHC 516/26/2019

51. Anesthetic Technique
Others
• Brain monitors- EEG ,Cerebral oximetry
• Urine output
• Point of care lab testing- ABG,Hct,
calcium,electrolytes Glucose, ACT
Department Of Anesthesiology , SGNHC 526/26/2019

52. Anesthetic Technique
• Extubation -should be smooth by avoiding
sympathetic stimulation
Department Of Anesthesiology , SGNHC 536/26/2019

53. Summary of Recommendations for
Anesthetic Consideration and Intraoperative
Management
Department Of Anesthesiology , SGNHC 546/26/2019

54. Anesthetic Technique
Regional anaesthesia
• Either spinal or epidural anaesthesia choices in
intermediate- and low-risk surgeries involving
extremities, perineum and lower abdomen.
• Strict guidelines followed-for those who are on
anticoagulant drugs.
• Central neuraxial blockade –hypotension-treated
with adequate preload and vasopressors such as
phenylephrine
Department Of Anesthesiology , SGNHC 556/26/2019

55. • A review of 9 systematic reviews of RCT
summarised the outcomes of neuraxial analgesia
with or without GA versus GA alone in patients
undergoing any type of surgery
• On comparison with general GA, use of neuraxial
blockade alone reduces 0–30-day mortality and
decreases the risk of pneumonia
Department Of Anesthesiology , SGNHC 56
Guay J, Choi P, Suresh S, Neuraxial blockade for the prevention of postoperative mortality
and major morbidity: An overview of Cochrane systemic reviews. Ccochrane Database Syst
Rev 2014:CD010108.
6/26/2019

56. Post op management
Goals
• To prevent ischemia
• Monitor myocardial injury
• Treat myocardial ischemia and infarction
Department Of Anesthesiology , SGNHC 576/26/2019

57. Post op management
• The patient monitored for ischemia by continuous ECG
in the CCU/ICU
• Effective pain management - to reduce stress, adverse
haemodynamics and hypercoagulable states
• Prevention of hypovolemia , hypotension hypoxemia ,
hypercarbia
• Adequate Hb concentration ( >7 gm/dl , above 80 years
> 8gm/dl)
• Weaning and extubation – careful – avoidance of
pressor response
Department Of Anesthesiology , SGNHC 586/26/2019

58. Summary Of approach To patient with
IHD
Department Of Anesthesiology , SGNHC 596/26/2019

59. Take home message
• All patients with IHD should have an assessment
of risk perioperative cardiac events
• Identification of risk factors is derived from history ,
physical examination
• Active cardiac conditions , clinical risk
factors,surgical risk factors and functional status are
the major outcome determinants in IHD patient
undergoing surgery
• Perioperative goals in patient with IHD-maintaining
a favorable myocardial supply and demand
relationship
Department Of Anesthesiology , SGNHC 606/26/2019

60. References
• Stoelting’s Anesthesia And co-existing Disease – 7th edition
• Morgan and Mikhail’s Clinical Anesthesiology – 5th edition
• Harrison’s principle of internal medicine-20th edition
• Perioperatve Myocardial Ischaemia in Non-cardiac Surgery
ATOTW 375 – 2018
• Hedge J, Balajibabu PR, Sivaraman T. The patient with
ischaemic heart disease undergoing non cardiac surgery.
Indian J Anaesth 2017;61:705-11
• 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing
Noncardiac Surgery
Department Of Anesthesiology , SGNHC 616/26/2019

61. Thank You
Department Of Anesthesiology , SGNHC 626/26/2019