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Perioperative Management Of

A Patient With Coronary


Artery Disease
Dr. Rajesh Arora MD
Senior Consultant And Head
Department Of Anesthesiology
Fortis Escorts Hospital Amritsar.
Objectives
To understand the implications and
risks of the coronary artery disease in
a patient undergoing non-cardiac
surgery.
How to minimise those risks and
conduct safe anesthesia in such a
patient?
To throw light on recent concepts and
guidelines in the management of such
patients.
Anesthetic management in special
situations and day to day dilemmas.
Guidelines for preoperative
evaluation and Care

ACC/AHA task force report :


Guidelines for perioperative
cardiovascular evaluation and care for
non-cardiac surgery
First published in circulation in 1996
Later updated in 2002 and 2007
Triggers •Surgical Trauma
•Anesthesia
•Intubation/extubation
•Pain •Anesthesia
•Surgical Trauma •Surgical Trauma •Hypothermia
•Hypothermia
•Anesthesia •Anesthesia •Bleeding/anemia
•Bleeding/anemia
•Fasting

Inflammatory Hypercoagulable Stress Hypoxic


State State State State

↑TNF-α ↑ PAI-1 ↑ catecholamine and


↓oxygen delivery
↑IL-1 ↑ Factor VII cortisol levels
↑IL-6 ↑ Platelet reactivity
↑CRP ↓ antithrombin III
Coronary artery shear ↑ BP
stress ↑ HR
Plaque fissuring ↑ FFAs
↑ relative insulin
Plaque fissuring deficiency

↑ Oxygen demand

Acute Coronary Myocardial


Thrombus Ischemia

Perioperative Myocardial Infarction


Myocardiac Ischemia Vs Myocardial
Infarction
• Myocardial ischemia is characterised by
metabolic O2 demand that exceeds the
oxygen supply
• MI : Death of portion of Heart tissue due
to lack of blood supply.
• Atherosclerosis is the common cause.
Preoperative Cardiac Issues
How healthy is the patient?
How active is the patient?
How risky is the planned surgery?
Is preoperative cardiac testing necessary?
What preventive measures can be taken to
reduce cardiac risk?

Risk Evaluation/Statification/Modification
Clinical Predictors of Increased
Perioperative Cardiovascular Risk
Major Clinical Predictors Intermediate Clinical Predictors
Unstable Coronary Syndromes
Acute or recent MI with evidence of
Mild angina pectoris (Canadian
important ischemic risk by clinical Class I or II)
symptoms or noninvasive study
Unstable or severe angina (Canadian Previous MI by history or
Class III or IV)
pathological Q waves
Decompensated heart failure
Significant Arrhythmias Compensated or prior heart
High-grade AV block failure
Symptomatic ventricular arrhythmias in
the presence of underlying heart disease Diabetes Mellitus (particularly
Supraventricular arrhythmias with
insulin-dependent)
uncontrolled ventricular rate
Severe Valvular Heart disease Renal Insufficiency
GRADES OF ANGINA
Canadian Classification of Angina
Class 0: Asymptomatic
Class 1: Angina with strenuous exercise
Class 2: Angina with moderate exertion
Class 3: Angina with mild exertion
1. Walking 1-2 level blocks at
normal pace
2. Climbing 1 flight of stairs at
normal pace
Class 4: Angina at Rest
FUNCTIONAL CAPACITY

Functional Capacity has


been classified as
Excellent ( >10 METs)
Good (7 to 10 METs)
Moderate (4 to 6
METs)
Poor ( < 4 METs)

What is one MET?


Who to test?
Noninvasive testing in preoperative patients indicated if 2
or more of following present:
 Intermediate clinical predictors (Canadian Class I
or II angina, prior MI based on history or pathological
Q waves, compensated or prior HF, or diabetes)
 Poor functional capacity (<4 METs)
 High surgical risk procedure (emergency major
surgery*, aortic repair or peripheral vascular,
prolonged surgical procedures with large fluid shifts or
blood loss)
Emergency major operations may require
immediately proceeding to surgery without
sufficient time for noninvasive testing or
preoperative interventions.
55 Years old man with history of hypertension & CAD but
asymptomatic runs for 30 minutes daily, needs inguinal hernia
repair. You are consulted to clear him for surgery.

1. Order Nuclear stress test to evaluate CAD.


2. Order Regular stress test
3. Order Cardiac catheterization
4. Order Echocardiography
5. Clear for surgery
What test?

If Clinical Assessment Not Sufficient, Go For


Specialized Investigations.
Ambulatory ECG monitoring/Holter.
Excercise Stress testing : TMT/Echocardiography
Angiography
Radionuclide Ventriculography
Dipyridamole- Thallium Scintigraphy To Be Done
What test?
Not
Wellwell
validated
validated
CTA
Exercise or pharmacologic echocardiography
MRI
Exercise or pharmacologic Cardiolite
Cardiac angiography*
Is testing predictive of outcomes?

Circ 1997; 95: 53


Cardiac event rates and dobutamine
echocardiography

JAMA 2001; 285:1865


Preoperative management
Revascularisation
Beta blockers
Alpha 2 agonists
Platelet inhibitors
Statins
sulphonylureas
Preoperative Risk Modification And Optimization

Revascularisation before
non-cardiac surgery
Coronary-artery revascularization
before elective major vascular
surgery
ACC/AHA 2004 Guideline Update for
Coronary Artery Bypass Graft Surgery
Benefit of CABG

Circ 1997; 96: 1882


Who Should undergo CABG before non-
cardiac surgery?
Patients undergoing

Elective non-cardiac procedures who are found to have


Prognostic high-risk coronary anatomy and in whom
Long-term outcome would likely be improved by CABG

should generally undergo coronary revascularization before a


noncardiac elective vascular surgical procedure or
noncardiac operative procedures of intermediate or high
risk
ACC/AHA 2004 Guideline Update for
Coronary Artery Revascularisation By PCI
CLASS IIa CLASS IIb
In patients in whom coronary 1. The usefulness of preoperative
revascularization with PCI is appropriate
for mitigation of cardiac symptoms and
coronary revascularization is not
who need elective noncardiac surgery in well established in high-risk
the subsequent 12 months, a strategy of ischemic patients (e.g., abnormal
balloon angioplasty or bare-metal stent dobutamine stress echocardiograph
placement followed by 4 to 6 weeks of with at least 5 segments of wall-
dual-antiplatelet therapy is probably
motion abnormalities).
indicated.
In patients who have received drug-eluting 2. The usefulness of preoperative
coronary stents and who must undergo coronary revascularization is not
urgent surgical procedures that mandate well established for low-risk
the discontinuation of thienopyridine ischemic patients with an abnormal
therapy, it is reasonable to continue aspirin dobutamine stress echocardiograph
if at all possible and restart the
thienopyridine as soon as possible.
(segments 1 to 4).
Single and Multivessel (Stable) CAD
Revascularization to Improve Survival (slide 1 of 2)
Anatomy Revasc COR LOE
Method
3 VD +/- Proximal CABG I B
LAD Disease*# PCI B
IIbOf uncertain benefit
2 VD With Proximal CABG I B
LAD Disease# PCI B
IIbOf uncertain benefit
2 VD Without CABG IIaWith extensive ischemia B
Proximal LAD C
IIbOf uncertain benefit without extensive
Disease#
ischemia
PCI IIbOf uncertain benefit B
1 VD With Proximal CABG IIaWith LIMA for long-term benefit B
LAD disease PCI B
IIbOf uncertain benefit
1 VD Without CABG III: Harm B
Proximal LAD disease
PCI III: Harm B
*Reasonable to choose CABG over PCI for good CABG candidates with
complex 3-vessel disease (e.g., SYNTAX score >22) (Class IIa; LOE:B)
#Reasonable to choose CABG over PCI for MVD in patients with DM (Class
IIa; LOE:B) GNL 2011
Single and Multivessel (Stable) CAD
Revascularization to Improve Survival (slide 2 of 2)
Clinical Setting Revasc COR LOE
Method
No anatomic or CABG III: Harm B
physiologic criteria PCI III: Harm B
for revascularization
LV Dysfunction CABG IIbEF <35% without significant B
left main CAD
PCI Insufficient data
Survivors of sudden CABG I B
cardiac death with PCI I C
presumed ischemia-
mediated VT

GNL 2011
Long-Term Survival among Patients Assigned to Undergo
Coronary-Artery Revascularization or No Coronary-Artery
Revascularization before Elective Major Vascular Surgery

5859 vets screened prior


to vascular surgery;4669
excluded
510 randomized to:
 Revascularization (258)
 99 CABG
At 2.7 years after randomization, mortality in the
 141 PCI
revascularization group was 22 percent and in the no-
 18 not revascularized
revascularization group 23 percent (relative risk, 0.98; 95
 252 nopercent confidence interval, 0.70 to 1.37; P=0.92). Within
revascularization
30 days after the vascular operation, a postoperative
 9 revascularized
myocardial infarction, defined by elevated troponin
 143 medical rx
levels, occurred in 12 percent of the revascularization
group and 14 percent of the no-revascularization
group (P=0.37).
McFalls, et al. NEJM 2004;351:2795-2804
DECREASE V showed that pre-operative revascularization did not improve the outcome
(composite endpoint: incidence of all-cause death or MI) for high-risk patients undergoing
vascular surgery.

Poldermans D et al. Eur Heart J Suppl 2009;11:A9-A14

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Patients With Bare Metal Stents
Undergoing Non-cardiac Surgery
A review on 424 patients with mostly BMSs suffered 82
adverse outcomes after non-cardiac surgery. There
were 6.6% cardiac death,5.4% non-fatal MI, and 5.4%
had evidence of myocardial damage.

Suggesting: BM stents don’t confer significant cardiac


protection.

“Howard-Alpe, Br J Anesth 2007”


Perioperative PCI/Angioplasty
angioplasty may be associated with adverse outcomes
in some populations ; Posner KL et al Anesth Analg 1999;

angioplasty/stent placement may result in acute


mortality if surgery follows in less than a month
(Catastrophic outcomes of noncardiac surgery soon after coronary stenting. (Kaluza GL,
Joseph J, Lee JR, et al. J Am Coll Cardiol 2000;35:1288 –94 )
Why ??
Due to many factors :
1. A possible lesser quality of or incomplete
reperfusion .
2. The release of inflammatory mediators
which predispose to stent thrombosis.
3. Untimely interruption of antiplatelet
therapy
PCI Before Anticipated Surgery
What If A Non-cardiac Surgery Patient Has To Undergo PCI For Optimization?
Acute MI
High Risk ACS
High risk anatomy

Bleeding risk of Low Stent and continued


anticipated Dual-antiplatelet rx
surgery
Not low

14 to 29 30 – 365 > 365


Days Days Days

Balloon Bare-metal Drug-eluting


angioplasty stent stent
Timing Of Surgery After PCI
What If A Post PCI Patient Presents For Non-cardiac Surgery?
Balloon Bare-metal Drug-eluting
angioplasty stent stent

< 14 days > 14 days < 30-45 days > 30-45 days < 365 days > 365 days

Surgery Surgery Surgery


Delay Delay Delay
with ASA with ASA with ASA
Dual antiplatelet therapy and surgery !!.. ??
Heparin/LMWH and surgery !!..??

Dilemma of bleeding & stent thrombosis


Heparin/LMWH and surgery !!..??

Until fairly recently the strategy was to


stop the clopid and/or aspirin one week
before any elective surgery in patients
with stent.
Unfractionated heparin or LMWHs are
not adequate to prevent stent
thrombosis.(Vicenzi, Br.J Anaes.2006)
Type of surgery
Some operations can be carried out successfully in
patients maintained on dual antiplatelet therapy.
Surgery in closed cavities Brain and eye cannot be
carried out under dual antiplatelet therapy.

Thyroidectomy …. ??
Preoperative Risk Modification And Optimization

Beta Blockers
Beta-blockade – Landmark Trials
Mangano DT et al. N Engl J Med 1996; 335: 1713-20.

200 patients scheduled for noncardiac surgery who had or


were at risk for CAD were randomized to receive either
perioperative atenolol or placebo.
Atenolol was started on the day of surgery and continued for
the length of the hospitalization to a maximum of 7 days.
No difference in the in-hospital cardiac morbidity/mortality
(as expected).
Prospective follow-up (for 2 years) showed a decrease in
overall mortality and increase in event free survival with
perioperative beta-blockade.
Perioperative cardiac care:
Beta-blockade – landmark trials
2- year survival =
90%

2- year survival =
79%

Mangano DT et al. N Engl J Med 1996; 335: 1713-20.


Perioperative cardiac care:
Beta-blockade – landmark trials
2- year event free
survival =
83%

2- year event free


survival =
68%

Mangano DT et al. N Engl J Med 1996; 335: 1713-20.


Beta-blockade – landmark trials
Poldermans D et al. N Engl J Med 1999; 341: 1789-94.

112 patients scheduled for elective major vascular


surgery (AAA repair or lower extremity
revascularization) with a positive dobutamine
echocardiogram randomized to bisoprolol or
placebo.
Bisoprolol was started at least 1 week preoperatively,
uptitrated if heart rate >60 bpm, and continued for
30 days postoperatively.
Dramatic reduction in 30-day postoperative cardiac
death and non-fatal MI.
Beta-blockade – landmark trials
Poldermans D et al. N Engl J Med 1999; 341: 1789-94.

Cardiac
death or
non-fatal
MI
Perioperative beta-blockade…what’s new
Recent Trials Showing No Benefit When Administered
In Unselected Patients

POBBLE trial (J Vasc Surg 2005; 41: 602-9.)


 103 patients without known CAD undergoing elective vascular surgery.
 Randomized to metoprolol (fixed dose) or placebo (started on admission, continued for up to
7 days).
MaVS study (Am Heart J. 2006;152:983-90.)
 496 patients undergoing elective vascular surgery.
 Randomized to metoprolol (fixed dose) or placebo (started on admission, continued for up to
5 days).
DIPOM trial (BMJ. 2006;332:1482-8.)
 921 patients with diabetes undergoing major, non-cardiac surgery.
 Randomized to metoprolol (fixed dose) or placebo (started 1 day before surgery, continued for
up to 8 days).
 Large (>300 hospitals, >700k patients), retrospective database study confirmed
reduced mortality in high and (probably) intermediate risk, but trend towards
harm in low risk. (Lindenauer PK et al. N Engl J Med 2005; 353: 348-61.)
Perioperative beta-blockade
PeriOperative ISchemic Evaluation (POISE) trial
190 hospitals, 23 countries, 8351 patients enrolled
Inclusion:
 >45 yrs old, expected hospitalization >24 hours, and: CAD; PVD;
prior stroke; hospitalization for CHF within 3 years; major vascular
surgery; or any 3 of the following: intrathoracic or intraperitoneal
surgery, h/o CHF, h/o TIA, DM, Cr >2.0, >70 yrs old, or
emergent/urgent surgery)
Exclusion:
 HR <50 bpm, 2nd or 3rd degree AVB, asthma, on beta-blocker or
planned periop beta-blockade, prior ADR with beta-blocker, CABG
within 5 yrs and no recurrent angina; low risk surgery; on verapamil.
Primary outcome = cardiac death, non-fatal cardiac arrest
or non-fatal MI

POISE study group. Lancet 2008;371:1839-47.


Perioperative beta-blockade: POISE trial
Randomized to metoprolol XL vs. placebo
1st dose metoprolol XL = 100mg, given 2-4 hours preop
If HR > 80 bpm or SBP >100 mmHg at any time first 6
hours after surgery, another dose of metoprolol 100mg
administered.
Daily dosage metoprolol 200mg thereafter x30 days
If HR < 45 bpm or SBP <100 mmHg consistently,
decrease metoprolol to 100mg qd

POISE study group. Lancet 2008;371:1839-47.


Perioperative Beta-blockade: POISE Trial
Metoprolol Placebo HR p value
Primary 244 290 0.84 0.0399
outcome (5.8%) (6.9%) (0.70-0.99)

Non-fatal 152 215 0.70 0.0008


MI (3.6%) (5.1%) (0.57-0.86)

Stroke 41 19 2.17 0.0053


(1.0%) (0.5%) (1.26-3.74)
Total 129 97 1.33 0.0317
mortality (3.1%) (2.3%) (1.03-1.74)

Primary outcome = cardiac death, non-fatal


cardiac arrest or non-fatal MI
POISE study group. Lancet 2008;371:1839-47.
Reducing Cardiac Risk In Non-cardiac Surgery: Evidence
From The DECREASE Studies
Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress
Echocardiography (DECREASE) series of studies
Trial Risk category Conclusion
Perioperative beta-blockade with bisoprolol significantly
DECREASE I High reduces cardiac death and MI in the short- and long-
term
Patients identified as intermediate risk on the basis of a
simple clinical assessment do not need pre-operative
DECREASE II Low, intermediate, high echocardiographic cardiac stress testing, provided that
they receive bisoprolol to maintain resting heart rate at
60–65 b.p.m.
In high-risk patients undergoing major vascular surgery,
fluvastatin XL significantly reduces myocardial ischaemia
DECREASE III High
and the combined endpoint of cardiovascular death and
MI
In intermediate-risk patients, bisoprolol significantly
DECREASE IV Intermediate reduces cardiac death and MI, with a non-significant
trend towards a beneficial effect of fluvastatin XL
In high-risk patients with extensive stress-induced
ischaemia, coronary revascularization (added to tight
DECREASE V High
heart rate control with bisoprolol) does not produce any
additional reduction in death and MI and delays surgery

Don Poldermans et al in Eur Heart J Suppl (2009) 11 (suppl A): A9-A14.


DECREASE IV trial showed that in high-risk patients undergoing non-cardiac surgery,
perioperative beta-blockade with bisoprolol significantly reduced the combined primary
endpoint of cardiac death and myocardial infarction.

Poldermans D et al. Eur Heart J Suppl 2009;11:A9-A14

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Beta blocker use?
Risk evaluation and cardiac complications in patients
undergoing major vascular surgery
2009 focussed update recommendations for
perioperative beta-blocker use
Perioperative cardiac care:
Beta-blockade…bottom line
For patients chronically receiving beta-blockers 
continue perioperatively
Which patients may benefit from prophylactic beta-
blockade, if any, is uncertain.
My opinion:
 High risk patients (RCRI ≥3) are likely to benefit
 Must be started days to weeks before surgery with dose
titration to achieve resting heart rate < ~70 bpm
Preoperative Risk Modification And Optimization

Statins
The Emerging Benefits
Statin
Lipid lowering effect Cardioprotective property

Statin

lipid TIMP-1

Lipid oxidation Collagen

Lipid inflammation

Matrix metalloproteinase-2

Cell death
Statin
Statins
 The ASTEROID trial :
Significant regression of atherosclerosis after intensive statin therapy
( rosuvastatin 40mg low LDL 60.8 mg/dl, increased HDL 14.7% )

 Leurs et al. :
In patients who underwent endovascular abdominal aortic aneurysm repair,
overall mortality rate at 5 years of follow-up was lower in those using statins,
compared to those not using statins

Continue with statins if


patient is already on statins
Statins
↓cardiac event

↓In-hospital length of stay Preserve renal function

↓Incidence of stroke
Strength of evidence for perioperative use of statins to
BMJreduce
2006; 333:1149
cardiovascular risk: systematic review of controlled studies
Statin - ongoing
DECREASE III study :
the effect of statin therapy on perioperative inflammatory
response and whether a reduced inflammatory response is
associated with improved cardiovascular outcome.

DECREASE IV trial :
whether β-blockers, statins or the combination of β-blockers
and statins are beneficial in 6000 moderate to high-risk
noncardiac, nonvascular surgery patients
DECREASE IV showed that in intermediate-risk patients undergoing non-cardiac surgery,
bisoprolol or bisoprolol plus fluvastatin significantly reduced 30-day cardiac death and
myocardial infarction.

Poldermans D et al. Eur Heart J Suppl 2009;11:A9-A14

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: journals.permissions@oxfordjournals.org
Preoperative Risk Modification And Optimization

Other agents/options
Calcium channel blocker Nitroglycerin

 Other agents/options

α2 adrenergic agonist
α2 Adrenergic Agonists
clonidine, dexmedetomidine, mivazerol

Reduce postganglionic noradrenalin output

In one prospective, randomized, placebo-controlled


clinical trial involving 190 patients with or at risk for
coronary artery disease and undergoing noncardiac
surgery, a reduction in perioperative mortality with the use
of clonidine has been demonstrated.
Pre operative risk reduction therapy
Preoperative Hb and Mortality
Study of Untreated Anemia

Carson, et al. Lancet. 1996;348:1055-60


Perioperative Hypothermia
300 pts undergoing
general surgery
Randomized,
double blinded
assignment to
routine care or
supplemental
warming

Frank SM JAMA 1997;227(14)


ANESTHESIA TECHNIQUES
VOLATILE Anesthetics
IV anesthetics
Regional anesthesia and analgesia
Regional Vs GA
INVASIVE Monitoring
GENERAL vs. REGIONAL ANESTHESIA
• NEURAXIAL ANAESTHESIA
• Decreases cardiac morbidity due to prevention of
thrombosis
• Decrease in afterload  reduction in O2 consumption
• Decrease CVS and metabolic stress response
• Reduction in deep vein thrombosis &post op RS depression

• Disadvantage – sympathectomy decrease in diastolic BP


• Clinical trials suggest no difference in infarction rate between
GA & RA
MONITORING
• NON-INVASIVE
• pulse oximetry
• Non-invasive BP

• Temperature monitoring

• End-tidal CO2 monitoring

• ECG Monitoring Monitors of Cardiac


• TTE/TEE Performance
• Urine output monitoring-Foley’s catheter
• INVASIVE
• Invasive arterial BP monitoring

• CVP monitoring
• Pulmonary artery catheterization
INVASIVE MONITORING
INDICATIONS :
• Hemodynamically unstable patients
• Major surgeries involving large fluid shifts &blood loss
• Pts. with acid-base &electrolyte imbalance
• To optimize fluid therapy
Pulmonary Artery Catheters

Patients most likely to benefit


Recent MI complicated by CHF
Patients with significant CAD undergoing procedures
associated with significant hemodynamic stress
Patients with systolic/diastolic dysfunction,
cardiomyopathy, and valvular disease undergoing high-
risk operations
Pulmonary artery catheter
Randomized clinical trial, 1994 high risk patients,
age > 60 yrs, ASA class III or IV, major noncardiac
surgery
No benefit with the use of pulmonary
artery (PA) catheters ??
The value of pulmonary Canadian Critical Care
artery and central venous Clinical Trials Group. A
monitoring in patients randomized, controlled trial
undergoing abdominal of the use of pulmonary-
aortic reconstructive artery catheters in high-risk
surgery: a comparative surgical patients.
study of two selected,
randomized groups.  Sandham JD, Hull RD, Brant RF, et al. N
 Isaacson IJ, Lowdon JD, Berry AJ, et Engl J Med 2003;348:5–14.
al. J Vasc Surg 1990;12:754–60.
Summary of evidence for PAC from clinical
trials
There are three interrelated variables that should be
assessed in determining the appropriateness of PAC
monitoring:
1. Patients should be examined for evidence of significant
organ dysfunction that may increase with hemodynamic
disturbances
2. Major surgical procedures may be associated with
hemodynamic disturbances and larger fluid shifts that may
damage organ systems
3. Benefits from PAC can be obtained only if the physicians
and nurses using the PAC demonstrate competence in the
basic technical and cognitive skills.
Hemodynamic Goals for the Patient with
CAD

Preload - keep the heart small, decrease wall


tension, increase perfusion pressure
Afterload - maintain, hypertension better than
hypotension
Contractility - depression is beneficial when LV
function is adequate
Rate - slow, slow, slow
Rhythm – NSR is the best.
Common Intraoperative Cardiac Conditions
 The most common Cardiac complications you may
encounter in the OR are:
1) ST Segment changes (Intraop Ischemia)
2) Myocardial Infarction
3) Sinus Bradycardia
4) Non-lethal Ventricular Arrhythmias
5) Pulmonary Edema
ST Segment Changes
Management:
1) Verify ST segment changes (check lead placement, compare to
previous EKG’s)
2) Ensure adequate oxygenation and ventilation (check pulse
oximeter, capnograph, send an ABG)
3) Maintaining
Treat tachycardia and/orCPP is absolutely
hypertension MUSTwith
(B-Blockade . Esmolol,
CPP
Labetolol, = Aortic
incr. depthdiastolic pressure (AoDP) - Left ventricular end-
of anesthesia)
diastolic pressure (LVEDP)
4) NTG IV Infusion, 0.25-2micrograms/kg/min; (titrate to desired effect)
5) Calcium Channel Blockade (Verapamil IV 2.5 mg, Diltiazem IV 2.5
mg
6) Intra-aortic Ballon Pump
Improves systolic run off
Provides diastolic augmentation
IABP

Systole

Systole
Balloon
deflates
9/25/18 WE Ellis 78
IABP
Diastole
Systole

Diastole
Balloon
inflates
9/25/18 WE Ellis 79
IABP

Systole

Systole
Balloon
deflates
9/25/18 WE Ellis 80
Case Presentation
50 yr old man with chest pain for
fem-pop bypass.

Hx:
 stable angina and old MI (plasty 7 yrs ago)
 no CHF or valvular disease
 DM, HTN, smoker
 fitness level: walks 30 minutes ok
Case Presentation
Physical Exam
 normal airway
 lungs clear to auscultation
 CVS:
 no cardiomegaly
 no S3
 no murmurs
Case Presentation
Meds
 beta blocker, ACE I, NTG prn

Labs
 Cr is elevated
 all other values normal
Case Presentation
Investigations:
ECG shows Q waves anteriorly. Otherwise is
normal sinus rhythm with borderline LVH
 Echo shows (4 years ago):
 EF 35%
 normal valves
 mild dilated cardiomyopathy
Preoperative Risk (AHA)
1. Are there any major patient risk factors?
 no
2. Are there any medium risk factors?
 yes: CRF, old MI, DM
3. Is the patient`s fitness level poor?
 no, fitness is ok
4. Is this a high risk surgery?
 yes
Preop Management
1. Is invasive testing indicated?
 no: no major risk factors present
2. Is non-invasive testing indicated?
 3 medium risk factors
 high risk surgery
 good fitness level
2 out of 3, therefore yes, it is indicated
3. Ok to proceed to surgery?
 no
Preop Testing
A cardiology consult is requested and the patient
receives an exercise treadmill test. The results are
favorable and no invasive monitoring is indicated.
Preop Preparation
Which drugs should be continued/stopped?
 beta blocker?
 continue!
 ACE I?
 stop (can result in vasodilation and BP)
 NTG?
… is prn and therefore not given
 Antiplatelet therapy?
 to continue with Aspirin, may stop Clopidogrel.
Anesthetic Monitors?
NIBP
SpO2
ECG … 3 lead or 5 lead?
A line?
CVP?
PA catheter?
TEE?
Emergency CVS Drugs?
ephedrine (yes)
phenylephrine?
IV beta blocker?
IV NTG?
dopamine?
dobutamine?
Anesthetic Technique
General vs. Neuraxial?
(neuraxial = spinal or epidural)

no method is superior with respect to MI, CHF,


mobidity or mortality, according to literature.
Anesthetic CVS Goals
 C: contractility
 R: rate
 R: rhythm
 A: afterload
 P: preload

“CRRAP”
Anesthetic CVS Goals
 C: low ( MVO2)
 R: low ( diastolic perfusion +  MVO2)
 R: sinus
 A: low ( MVO )
2

 P: low ( MVO2)

Must balance  MVO2 with perfusion


Intraoperative
 Uneventful GA with ETT, with stable CVS
 At start of surgery, BP150/90 and HR 120
 ECG shows ST depression 2 mm in lead II

What is the problem?


How do you manage?
Please discuss.
Intraoperative Ischemia
Why is ischemia present?
 surgical stimulus   sympathetic drive

  afterload   work for myocardium


  contractility  work
  HR  work
  HR  diastolic perfusion

 O demand > O supply


2 2
Intraoperative Ischemia
How do you manage this problem?

 Goal:  O2 supply and  O2 demand


 Method for this case:  sympathetic drive
Intraoperative Ischemia
Options:
 Stop surgery (stimulus, pain), give additional
analgesics(narcotics), depth of anesthesia
 Beta blocker/Calcium channel blockers

 Maintain BP/CPP

NTG? probably not so useful for this patient


Heparin: definitely not useful
Two hours later
HR is 100, BP is 90/50
ECG shows ST depression 2 mm in lead II

How do you manage THIS ischemia?


Intraoperative Ischemia (2)
Goal:  O2 supply and  O2 demand

Need a diagnosis:
 is O demand a contributor?
2

 is O2 supply a contributor?

Please discuss!
O2 Demand
 HR of 100 is moderately high
 afterload not elevated
 contractility unknown

Would you give a beta blocker?


O2 Supply
Depends on
 coronary anatomy (stenosis)
 blood pressure

 diastolic time (determined by HR)

 O content of blood
2

Which factors can we modify in OR?


Factors to modify
 coronary anatomy (stenosis)
 no
 blood pressure
 yes
 diastolic time (determined by HR)
 yes

O content of blood
2
yes
Blood pressure
use vasopressors
avoid inotropes
increased HR and contractility
ensure adequate preload
Diastolic Time
Elevated HR caused by:

 inadequate anesthesia

 inadequate preload
 anemia
 hyperthermia
Oxygen Content/Delivery of Blood
Determined by:
Hb
SaO2
CO
Back to the Case
 Look at the filling pressures
 there has been 1000 cc of blood loss
 Hb=8.0 CVP=5 90/50 HR=100

What do you do?


1. give vasopressor?
2. give crystalloid or colloid?
3. give blood?
Postop
 clearly the patient has coronary disease although the
results of the treadmill were favorable (false negative)
 patient requires cardiology re-assessment and
angiography
Intraop Ischemia
Conclusion
Occurs when O2 demand > O2 supply

2 sides of the equation


 analyze all possible causes
 each patient requires individual treatment
Post Operative Period
First 24-72 hrs are critical
Strict monitoring
Adequate analgesia
Optimum environment
Oxygenation
Continue previous medications like beta-
blockers
Improved Cardiac Care For Noncardiac
Surgery?
Yes, we can!
THANK U