Anesthetic implications of cardiovascular disease. objectives. To identify the patients at risk for peri -op cardiac complications.
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1) risk factors
2) active cardiac condition
3) previous MI, prior cardiac evaluation
4) past interventions – CABG,PTCA
5) functional capacity (NYHA)
6) co-morbid conditions
Rate of major cardiac complications-
0 – 0.5 % 1- 1.3%
2 – 4% >3 – 9 %
"Low risk": if 0 factors, risk = 3.1%; no additional pre-op testing needed
"Intermediate risk: if 1-2 factors, risk = 15%; noninvasive testing with angio if inducible ischemia.
"High risk: if > 2 factors, risk = 50%; go straight to angiography.
STEP 3:determination of the surgical risk or severity. Patients without active cardiac conditions who are undergoing low-risk surgery can proceed to surgery without further cardiac testing.
Dipyridamole/adenosine thallium scintigraphy
RESTING ECHO: to detect presence & significance of valvularheart ds,to detect CHD, LVEF, chamber enlargement & hypertrophy
STRESS TESTING: Exercise stress alone (usually Bruce protocol),Exercise / pharmacological stress with nuclear myocardial perfusion imaging (MPI), stress echo (Pharmacologic or exercise).
Pharm stress echo: Unable to exercise or Inability to achieve target heart rate during exercise because of therapy with High dose beta-blocker or calcium channel blocker
-To detect or exclude serious CAD i.e. left main or 3 vsds.
-chronic stable angina pts who are severely symptomatic despite medical therapy
-Pts with ventricular dysfxn
-In young patients with VHD to rule out assoc. CAD before cardiac surgery.
-patients being considered for revascularization -Helps to decide how many bypass grafts should be performed
- for definitive diagnosis of CAD individuals whose occupations could place others life in danger( pilots)
routinely administer all antihypertensive drugs preoperatively, except ACE inhibitors or angiotensin II antagonists , which is tailored to the individual patient, due to risk of intra operative hypotension.
IHD/ CAD: Vasodilationwith nitroglycerine, nitroprusside, prazosin in order to decrease ventricular wall tension. Allaying fear, anxiety and pain preoperatively are desirable goals in patients with CAD to prevents sympathetic activation, which affects myocardial oxygen supply–demand balance. To continue beta blockers (dosages adjusted to achieve an HR lower than 70 beats/min)statins, antihypertensivesshould be continued.
Continue aspirin therapy in all patients with a coronary stent and discontinue clopidogrel for as short an interval as possible for patients with bare-metal stents in place for less than 30 days or drug-eluting stents for less than 1 year.
HEART FAILURE: may be systolic, diastolic or both. Hypertension is a cause of diastolic dysfunction, and LVH on an ECG should raise suspicion. Ischemic heart disease is the most common cause of systolic dysfunction.
VALVULAR HEART DISEASE: Murmurs: D/t turbulent flow across the defective valve. Note the character, location, intensity, direction of radiation.Systolicmurmurs: AS, PS or MR,TR. Diastolic murmurs: MS, TS or AR, PR. Dysrhythmias: AF (esp Mitral valve ds.) i.e. with enlarged Lt atria. Predisposed to thromboembolic phenomenon. benign murmurs occur with high-outflow states such as hyperthyroidism, pregnancy, or anemia.
ARRYTHMIAS: Bradyarrhythmias, especially if profound or associated with dizziness or syncope, are generally managed with pacemakers.
Most opioids, hypnotics, and volatile anesthetics have been used successfully in different combinations for induction and maintenance of anesthesia. Anesthetic drugs and doses are selected according to two main considerations, the first being LV function.