Management of Anesthesia in Patients with Ischemic Heart Disease undergoing Noncardiac Surgery Dr. Alireza Pournajafian – Assistant Professor of Anesthesia Tehran University of Medical Science

Preoperative Assessment Main Goals : - Determining the extent and severity of ischemic disease - Identifying the patients at risk of perioperative cardiac complications (e.g. myocardial infarction) - Reviewing any medical therapy or previous cardiac surgery

Cardiac Risk Factors I. High risk surgery : Aortic aneurysm, Thoracotomy, major abdominal operation II. Ischemic Heart Disease : Hx. Of MI , positive exercise test, current angina, Q wave on ECG, use of nitrate III.CHF: Hx. Of P.E. , PND, Rales or S3 in auscultation IV. Cerebrovascular : Hx. of stroke or TIA V. IDDM VI. Creatinine > 2 mg/dl

Conditions that Increase Perioperative Cardiac Complications Increased myocardial oxygen requirements Change in coagulation status Tendency to thrombosis in veins Changes in vascular tone and endothelial function

Preoperative Visit Optimum Anti-ischemic and Antihypertensive therapy before operation Preventing sympathetic system stimulation ( control pain and anxiety) Conditions that cause silent ischemia (e.g. Diabetes)

Conditions that correlate with perioperative morbidity and can be corrected before surgery: Recent MI Sever CHF Some Dysrhythmia Chronic Renal Insufficiency Electrolyte Imbalance

Significant intraoperative factors that correlate with perioperative risk and may be avoided or altered: Unnecessary use of vasopressors Hypotension Hypothermia Very low or very high hematocrit

NYHA Classification . Class I: no limitation of physical activity; ordinary activity does not cause fatigue, palpitations, or syncope    . Class II: slight limitation of physical activity; ordinary activity results in fatigue, palpitations, or syncope    . Class III: marked limitation of physical activity; less than ordinary activity results in fatigue, palpitations, or syncope; comfortable at rest    . Class IV: inability to perform any physical activity without discomfort; symptoms at rest

Metabolic Equivalents of Functional Capacity 1- Eating, working at a computer, dressing 2- Walking down stairs or in your house, cooking 3- Walking 1-2 blocks 4- Raking leaves, gardening 5- Climbing 1 flight of stairs, dancing, bicycling 6- Playing golf, carrying clubs

Metabolic Equivalents of Functional Capacity 7- Playing singles tennis 8- Rapidly climbing stairs, jogging slowly 9- Jumping rope slowly, moderate cycling 10- Swimming quickly, running or jogging briskly 11- Skiing cross country,playing basketball 12- Running rapidly for moderate to long distances

Simplified cardiac evaluation for noncardiac surgery Step1: Emergency Surgery → → proceed to surgery Step2: Active cardiac condition → → Postpone surgery Step3: low risk surgery(<1%) → → proceed to surgery Step4: Good FC ( > 4Mets ) → → proceed to surgery

Simplified cardiac evaluation for noncardiac surgery Step5 Clinical Predictors : ( IHD, Hx. CHF,CVA, DM, RF ) NO → → → → proceed to surgery 1-2 predictors + vascular or intermediate risk surgery → → noninvasive tests before surgery ≥ 3 + vascular surgery → → invasive testing ?! (if it will change management)

Perioperative monitoring Influenced by the complexity of the operation , severity of ischemia and preoperative myocardial function Blood Pressure, Arterial Oxygen Saturation, Heart Rate, ECG Pulmonary Artery Catheter TransEsophageal Echocardiography

Induction of Anesthesia . Most intravenous anesthetics except Ketamin . Depolarizing or Nondepolarizing Muscle Relaxant (Vecuronium,Rocuronium,Cisatracurium ) . Drugs for blunting sympathetic responses due to tracheal intubation

Maintenance of Anesthesia Based on decreasing sympathetic stimulation and exact control of hemodynamic changes Balance between delivered oxygen to patient and myocardial oxygen requirements

Maintenance of Anesthesia Volatile Anesthetics Infusion of Intravenous Anesthetics Opioides + nitrous oxide Avoid Hyperventilation Regional Anesthetia

Postoperative Managements Continous ECG monitoring Prevent Hypothermia and Shivering Control Postoperative Pain Myocardial infarction risk after 48 to 72 hours after surgery

Preoperative Management of patients receiving Antiplatelet Aspirin(75-150mg/d) (MI,ACS,Stent,stroke,PAD) Secondary prevention All surgery Operation under continous treatment Intracranial surgeries Primary prevention Stop 7 days before operation

Preoperative Management of patients receiving Antiplatelet Aspirin(75-150mg/d)+Clopidogrel(75mg/d) BMS,stroke,<12m after DES) High risk(<6w MI,PCI, Only vital surgeries continous treatment Operation under Risk of bleeding in closed spaces Low risk situations All surgeries Stop clopidogrel, maintain aspirin

Management of a patient with a previous percutaneous coronary intervention Previous PCI Balloon angioplasty Bare-metal stent <14d Delay elective surgery >14d >30-45d Operation with aspirin <30-45d <1y Drug-eluting stent >1y

ASA ASA 1: Healthy patient without organic, biochemical, psychiatric disease ASA 2 : mild systemic disease, no significant impact on daily activity ASA 3 Significant or severe systemic disease that limits normal activity, e.g., renal failure on dialysis or class 2 congestive heart failure. Significant impact on daily activity. ASA 4 Severe disease (threat to life or requires intensive therapy), e.g., acute myocardial infarction, respiratory failure requiring mechanical ventilation. Serious limitation of daily activity. ASA 5 Moribund patient who is equally likely to die in the next 24 hours with or without surgery ASA 6 Brain-dead organ donor