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

2. 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

3. 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

4. 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

5. 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)

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

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

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

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

18. 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

19. 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

20. 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

21. 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