Cardiology, Course Material

Anaesthetic considerations in a patient with ischaemic heart disease posted for non-cardiac surgery.

07 Apr

ISCHAEMIC HEART DISEASE:

Major noncardiac surgery is associated with an incidence of perioperative cardiac death of 0.5–1.5% and major cardiovascular complications (e.g. myocardial infarction, heart failure and stroke) of 2–3.5%. These complications are much higher in patients with recent MI or unstable angina who require urgent or emergency surgery. An anesthesiologist should be aware of the pathophysiology and the need to thoroughly

evaluate the patient for peri-operative management.

Classification of CAD:

  1. Stable CAD:
    1. Stable angina pectoris.
    1. Vasospastic angina (Prinzmetal variant angina).
    1. Microvascular angina (syndrome X).
    1. Angina associated with the myocardial bridging of coronary arteries.
  2. Acute coronary syndromes (ACS)
    1. ST-elevation myocardial infarction (STEMI)
    1. Non-ST elevation ACS (NSTE-ACS):
      1. Non-ST-elevation myocardial infarction [NSTEMI] (associated troponin rise).
      2. Unstable angina (no myocardial cell necrosis/troponin increase).

Aetiology of IHD:

  • Coronary artery thrombosis: Insufficient Oxygen supply owing to narrowing of coronary arteries is the most significant cause of IHD.
  • Coronary artery spasm (Prinzmetal variant angina, illicit drug use [eg, cocaine], or discontinuation of nitrates).
  • Coronary artery embolism.
  • Vasculitis of the coronary arteries.
  • Metabolic disorders affecting the coronary arteries.
  • Anatomic defects of the coronary arteries.
  • Coronary artery injury.
  • Arterial thrombosis due to disorders of hemostasis
  • Reduced oxygen supply unable to meet the demand (aortic stenosis or regurgitation, hypertrophic cardiomyopathy, carbon monoxide poisoning, decompensated thyrotoxicosis, long-standing hypotension [shock]), anaemia, myocardial bridging), or aortic dissection.

Click here to download the complete module on Ischaemic heart disease.
Pre-op evaluation, the cardiac risk scores, optimisation strategies and perioperative management of patients with ischemic heart disease posted for non-cardiac surgery make up a significant bulk of questions asked in various post-graduate anaesthesia examinations. Candidates sitting in these exams must have a thorough understanding of the topic.

Perioperative ischaemia and management are some of the examiner-favourites’ whether as MCQ or in table viva.
In this chapter, we have comprehensively covered the major concerns associated with the presence of ischemic heart disease in a patient posted for non-cardiac surgery with due regards to syllabus recommendations of the European/UK board syllabus for EDAIC/FRCA.

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