5. WHAT IS IHD ?
❖ IHD : Generic designation given to group of related syndromes resulting from
myocardial ischemia - an imbalance between the oxygen demand and supply
❖ RISK FACTORS :
1. Male gender, Increasing Age, Genetic factors/Family.
2.Hypercholesterolemia, Hypertension, Cigarette smoking , Diabetes
Mellitus, Obesity , Sedentary Lifestyle.
7. ANGINA PECTORIS
❖ Angina Pectoris : -
Symptom complex of IHD characterised by Paroxysmal and usually recurrent
attacks of substernal or precordial chest discomfort , pain, pressure /heaviness
often radiating to neck, left Shoulder /arm /jaw. -Reflects intracardia
release of Adenosine, Bradykinin and other substances.
❖ Stable Angina :
-Chronic pattern of transient angina pectoris precipitated by physical exertion or
emotional stress, relieved by rest/ nitroglycerin
❖ Unstable Angina :
-Angina at rest , Angina of new onset or increase in severity of frequency of
previously stable angina without an increase in level of cardiac biomarkers.
8. ACUTE
CORONARY
SYNDROME
❖ Hypercoagulable state - focal
disruption of atheromatous
plaque & propagation of
thrombus formation leading
to partial or complete
obstruction of coronary artery
❖ STEMI
❖ NSTEMI/Unstable Angina
20. PREOP WORKUP CONTD.
❖ECHOCARDIOGRAPHY :
- Ventricular wall motion abnormalities can help to localise
the obstructive coronary lesions.
- Visualize Global wall motion under baseline conditions and
under cardiac stress.
- Valvular function can also be assessed
❖STRESS ECHOCARDIOGARPHY :
- Cardiac stress induced with pharmacologic (Dobutamine) or
Exercise stress to look at LV segmental wall function
- Differentiates viable (Hibernating , stunned ) & Non-viable
(Infarcted segments )
24. ❖ RISK STRATIFICATION
❖ MANAGEMENT PRIOR TO SURGERY : -
Revascularization by surgery
-Revasularization by PCI
-Optimal medical management
❖ PERIOPERATIVE MYOCARDIAL ISCHEMIA
❖ INTRAOPERATIVE MANAGEMENT AND POST-OPERATIVE
MANAGEMENT
25. RISK STRATIFIACTION
❖ GOAL : Identify patients at increased risk so as to manage them that can lessen
the risk & severity of peri-operative cardiac events ( Cardiac death , VF, Heart
blocks , Acute MI , pulmonary embolism ) .
HOW ITS DONE ?
1. Determining extent of Ischemic Heart disease
2. Previous Interventions
3. Assessing severity and stability of disease
4. Reviewing Medical treatment
26. GUIDELINES AND CRITERIAS
FOR RISK STRATIFIACTION
1. LEE’S REVISED
CARDIAC RISK INDEX :
Score. Risk
0 0.4%
1 1.0%
2 2.4%
3 5.4%
27. 2.ACC/AHA CLINICAL
PRACTICE GUIDELINES
2014 :
Multistep approach , Integrates
risk stratification according to -
(I) Clinical Risk factors
(II)Functional Capacity
(III) Surgery specific Risk
factor
28. (II) FUNCTIONAL CAPACITY :
-Expressed in Metabolic Equivalent of the task (MET) units .
-O2 Consumption in resting state : 3.5ml/kg/min = 1 MET .
-<4MET : Poor functional capacity , >4 MET : Moderate , >9MET : Excellent
Functional capacity .
29. (III) SURGICAL SPECIFIC RISK FACTORS :
-High Risk Surgeries : Emergency major surgery , Aortic /Major vascular
surgeries, Peripheral Vascular surgeries , Surgery with Major fluid shift/ Blood
loss. (MACE > 5%)
-Intermediate Risk Surgeries : Carotid endareterectomy, head and neck
surgeries, intraperitoneal/intrathoracic surgery, orthopaedic surgery & Prostate
surgery . (MACE 1-5%)
-Low Risk Surgeries : Endoscopic procedures, Superficial procedures , Breast
surgeries, Cataract surgeries & Ambulatory surgeries ( MACE < 1%).
30.
31.
32.
33. OTHER CRITERIAS AND GUIDELINES
❖Modified Goldman criteria
❖American College of
Surgeons NSQIP MICA.
34. MANAGEMENT PRIOR TO SURGERY
1. REVASCULARIZATION BY SURGERY : Coronary Artery By-pass Graft
2. REVASCULARIZATION BY PCI :
-Angioplasty
-Bare metal stents
-Drug Eluting Stents
3. Optimal Medical Management
35. AFTER PCI , THINGS TO KEEP IN
MIND
❖ 1. PCI - Surgery interval.
❖ 2. Continuation of Dual Anti platelet therapy .
❖ 3. Peri-operative Monitoring Strategies : Intra-
operative continuous ECG monitoring with ST
analysis
❖ 4. Anaesthetic technique : Regional
Anaesthesia YES/NO ?
❖ 5. Availability of Interventional Cardiologist
(within 90 minutes).
37. PERIOPERATIVE MYOCARDIAL
ISCHEMIA
❖ Incidence : Cumulative result of patients preoperative medical condition ,
specific surgical procedure, Experience of Surgeon
❖ Most peri-operative MI : 24-48 hours after surgery , MC : NSTEMI (difficult
to diagnose )
❖ Diagnosis : Based on symptoms , ECG and markers (Trop I ).
40. INTRAOPERATIVE MANAGEMENT
❖ Goals : 1.Prevent Myocardial
Ischemia - by optimising myocardial
O2 Delivery and reducing O2 demand
- Premediaction , Induction And
Maintenance and post-operatively
❖ 2.To monitor for Ischemia : Vigilent
Monitoring
❖ 3.Appropriate measures to Treat Intra-
op Ischemia if it develops
41. ❖ PRE-MEDICATION :
Benzodiazepines (Anxiolytic, Hemodynamic stability )
Intravenous opioids (Fentanyl -Effective control of Catecholamoine surge )
❖ INDUCTION :
-Thiopentone : Decreases Myocardial contractility (pre-load/ after load ,BP )
-Propofol : Dose dependant decrease in myocardial contractility and produces significant
drop in BP and HR ( not suitable in patients with LV dysfunction )
-Etomidate : Drug of choice (minimal Hemodynamic changes )
- Ketamine : Avoided
- Intubation : preferably to be done in <15 secs facilitated by use of DMR
-Blunting of Intubation reflexes can be done ( iv/laryngotracheal lidocaine , fentanyl ,
dexmeditomidine )
42. ❖ MAINTENANCE :
-Volatile Anaesthetics : (AHA guidelines) - beneficial to use in non cardiac
surgery : Decreases myocardial oxygen requirements (Use of N2O
questionable)
-Muscle Relaxants : Vecuronium, Rocuronium , Cisatracurium are attractive
choices for patients with IHD . Pancuronium (sympathomimetic activity ) &
Atracurium (Histamine release ) are less desirable agents .
-Opiods : Important role in supplementing Anaestehsia (Offers Stable
Hemodynamics)
❖ TECHNIQUES: Regional Anaesthesia may be preferred / Combined GA+RA
43. ❖ INTRAOPERATIVE MONITORING
&INTRA-OP MI Mx:
- Vitals monitoring
- Continuous ECG monitoring with ST-
segment analysis (Lead II, V3,4,5 ):
Important to detect MI events intro
-Proper Pain control , Avoid Shivering ,
Prevent hypo/Hpercarbia , hypovolemia ,
hypotension .
50. PREOPERATIVE CONCERNS
❖ PRE-OPERATIVE EVALUATION : —
vDetermine adequacy of blood pressure control
vReview pharmacology of drugs being administered
vEvaluate for evidence of end organ damage
vContinue drugs used for control of blood pressure
❖ EXAMINATION AND DIAGNOSTIC WORKUP: To rule out HMOD &
Secondary Hypertension
❖ PRE-OPERATIVE OPTIMISTION OF BLOOD PRESSURE.
51. INTRA-OPERATIVE CONCERNS
❖ PRE-MEDIACTION :Aimed at Anxiolysis
❖ INDUCTION AND MAINTENANCE : Blunting of laryngoscopic reflexes(iv
esmolol, lignocaine, IV labetalol, Volatile Anaesthetics). Minimise wide
fluctuations in blood pressure [Both Intraop Hypo/hypertension common]
❖ MONITORING : Invasive BP monitoring if needed , monitor for MI
❖ POSTOPERATIVE CONCERNS : Anticipate periods of systemic HT and
monitor for end organ damage .
