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Ischemic heart disease for noncardiac surgery Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics, PhD(physiology) Mahatma Gandhi Medical College and Research Institute, Puducherry, India • IHD is vast • Non cardiac surgery is an ocean • Just I am going to touch some points Preoperative workup • • • • • • history, physical examination, investigation, clinical risk predictors, risk assessment, functional capacity. Preoperative workup • Who should do ?? • Wait for clearance is ??? • We should do !! History • 1. Angina at unaccustomed work. No limitation of physical activity • 2. Angina on moderate exertion. Mild limitation of physical activity • 3. Angina on mild exertion. Marked limitation of physical activity • 4. Angina at rest • NYHA grades history • • • • • • H/o Dyspnoea oedema H/o of M.I , F/H/O CAD Co morbid conditions current medications Physical examination • • • • • • • Look for cyanosis, pallor, dyspnea during conversation, nutritional status, skeletal deformities, tremors & anxiety, assessment of vital signs , JVP pulsation, carotid bruit, oedema. MET 3.5 ml/kg/min. MET Functional Levels of Exercise • • • • • • • • • • • • 1 Eating, working at a computer, dressing 2 Walking down stairs or in your house, cooking 3 Walking 1-2 blocks 4 gardening 5 Climbing 1 flight of stairs, dancing, bicycling 6 Playing golf, carrying clubs 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 full-court basketball 12 Running rapidly for moderate to long distances METS • <4 • 4- 7 • >7 Vital point • Elective surgery in patients with a history of AMI should be delayed up to 6months after the episode of AMI if possible. Investigations • All routine investigations • ECG and special 12 Lead ECG ECG (Preoperative resting) • Q waves – Magnitude & extent – Estimate of LVEF & long term mortality • ST segment depression Adverse – Horizontal/downsloping > 0.5mm perioperative cardiac events • LVH with “strain pattern” • LBBB with established IHD Within 30 days of surgery, Both Preop. & Postop. ECG Anteroseptal ST elevation Q waves (V1 – V4) ST depression I, V3 – V6 LV strain pattern Leads I, aVL, V4-V6 T wave inversion LBBB Broad QRS complex Certain terminologies Revised cardiac risk index (Lee) • High-risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures) • IHD • History of congestive heart failure • History of cerebrovascular disease • Diabetes mellitus requiring insulin • Creatinine >2.0 mg/dL • 0 = 0.4%, 1 = 0.9%, 2 = 7%, >3 = 11 % • IIICCC Surgical risk • High (Cardiac risk often >5%) – Emergency surgery (specially in elderly) – Aortic/major vascular/peripheral vascular surgery – Major surgery with large fluid shifts/blood loss • Intermediate (Cardiac risk generally <5%) – Carotid endarterectomy, Head & neck – Intraperitoneal, Intrathoracic, Ortho, Prostate • Low (Cardiac risk generally <1%) – Superficial procedure, Cataract, Endoscopy, Breast Clinical Predictors of Increased Perioperative Cardiovascular Risk • • • • Physical capacity Surgery Cardiac risk index Clinical predictors • Three sentences to follow !! • Perioperative risk with non vascular surgery, non high risk is low • Chronic stable angina 4 - METs • Revascularization 5 years prior with stable symptoms • Is there a need for evaluation ?? Preoperative exercise stress testing?? • Preoperative exercise stress testing is usually not indicated in patients • with stable coronary artery disease and acceptable exercise tolerance. • Because the exercise ECG can produce a number of false-negative and false-positive results, its predictive value is limited. Investigations • Exercise ECG • Patients unable to exercise – Radionuclide Myocardial Perfusion Imaging Induce hyperaemic response: Coronary vasodilator Dipyrimadole/Adenosine Thallium 201 imaging – Dobutamine stress echocardiography Increase myocardial O2 demand: Dobutamine • Cardiac CT • Echocardiography Induced Ischaemia • ST segment depression – Horizontal or downsloping > 0.1 mV • ST segment elevation – >0.1 mV in noninfarct lead • Abnormal leads: 5 or more • Ischaemic response – Persistent > 3 min after exertion • Typical angina • Exercise induced fall in Syst. BP by 10 mmHg ECHO • Size of chambers – Dimension/volume of cavity – Wall thickness • Pumping function – Ejection fraction • Regional wall motion abnormalities – Hypokinesia, Dyskinesia, Akinesia • Valve function • Diastolic dysfunction Cardiac CT Reconstruction • Dobutamine stress echocardiography • RWMA at 60 % predicted heart rates – cardiac risk • Myocardial perfusion imaging • More than 20 % defect • Reversible – more dangerous Medications • • • • Beta blockers Statins Alpha agonists Smoking cessation, hypertension, diabetic control • Diuretics , antiplatelets – case to case • Nitroglycerines Anti platelets • Aspirin (Low dose) – Cardiovascular risk > Bleeding risk – continue – Prostatectomy & Intracranial surgery- discontinue • Clopidogrel (Elective Surgery) – With hold for 1 week – If cardiac risk high: LMWH • Dual therapy/Emergency surgery – Platelet transfusions – Haemostatic agents Preoperative PCI • The indications don’t change with surgery or not innumerable protocols Goldman risk index • • • • MI within 6 months, Age>70 Emergency AS, arrhythmias S3 gallop, increased JVP Don’t think operation or not !! • • • • • Do we need investigations Do we need PCI Do we need CABG Does not change much !! Beta blockers, statins , alpha agonists, Ca C inh, digitalis to continue • Warfarins ?? And LMWH Intraoperative management • ST segment monitoring and analysis (II, V4,V5 – 96%) • Temperature Core temperature >35OC • Blood sugar control (Insulin) <150 mg% • CVP ?? Arterial line – case to case basis , PAC ?? – Risk of major haemodynamic disturbances • TEE Emergency use three times as ECG, looking like a cell phone – preintubation ?? – Acute, persistent haemodynamic instability ECG • The introduction of ST-segment trending helps as an early warning detection system but should not replace examination of the ECG printout. • 15 % - 40 % changes Perioperative arrythmias • no details • SVT VT sustained or not • Ca channel blockers, • digoxin • adenosine, amiodarone Beta blockers lignocaine Cardioversion Myocardial oxygen balance DECREASE O2 SUPPLY Decreased CBF tachycardia hypotension increased preload hypocapnia ↓ Oxygen content anemia Hypoxemia decreased release – ODC - Lt INCREASED O2 DEMAND • Tachycardia • Increased wall tension ↑ preload ↑ afterload • Increased contractility Anaesthetic technique • Regional block – Better ablation of catecholamine response – Decreases preload and afterload – Less hypercoagulable state – Limit use to infra-umbilical procedures • Volatile anaesthetics (Maintenance) – Beneficial (In haemodynamically stable) – Cardioprotective: Decrease troponin release – Pre & Post condition against infarction – N2O – increased PVR, DD, homocysteine increase Anaesthetic technique • Subarachnoid block – Bupivacaine + Fentanyl • General Anaesthesia + Epidural • Monitored anaesthesia care – L.A + Intravenous sedation/analgesia – Ensure satisfactory local anaesthetic block – Dexmedetomidine (short acting 2 agonist) Can we have ?? • • • • • • • • High spinal Pancuronium Pethidine Ketamine Etomidate Benzodiazepines Remifentanyl Phenylephrine • • • • iV lignocaine Smooth extubation Atropine Atracurium • Vecuronium • mivazerol (IV form only available in Europe) Nitroglycerin • Role unclear • Intravenous NTG – Compounds vasodilation (Anaesthetics) – Cardiovascular decompensation – Monitor intravascular status (CVP) • Topical NTG – Uneven absorption – Ischemia detected – other drugs ?? – then use Predictors of postoperative myocardial ischaemia • • • • • • • Left ventricular hypertrophy History of hypertension Diabetes mellitus Known ischaemic heart disease Use of digoxin 8 -24 hours , upto 40 % of high risk patients Previous !! Postoperative period • Say No to • • • • • Hypoxemia Shivering Pain -sepsis, bleeding-------Monitoring , enzymes Summary • • • • • • • METs Risk index Surgical Drugs , IHD and anaesthetic SA or GA – monitoring Maintain balance Post op – say no to ?? Homework • IHD - met 5 and hernioraphy • IHD, PCI done for TURP • CABG done on clopidogrel for DU perforation • IHD with mild AS for DHS . 75 years male Thank you all