In the Name of God

1. In the Name of God Anesthesia for noncardiac surgery in patients with ischemic heart disease Dr. Emampour

2. Anesthesia for noncardiac surgery in patients with ischemic heart disease • Patients with ischemic heart disease undergoing noncardiac surgery are at increased risk for perioperative cardiovascular events, such as myocardial infarction, heart failure, and mortality. Those with recent myocardial infarction or unstable angina are at very high risk if they require urgent or emergency surgery.

3. PREANESTHESIA CONSULTATION • Recent myocardial infarction or unstable angina • Recent percutaneous coronary intervention • Urgent or emergency surgery • High-risk surgical procedure

4. Preoperative medication management • Beta blockers • Statins • Aspirin • Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers • Clonidine • Other cardiovascular medications

5. Percutaneous Coronary Intervention and Thrombosis • multiple pathways must be blocked to achieve clinically effective platelet inhibition. • Dual antiplatelet therapy (aspirin with a P2Y12 inhibitor) is better • P2Y12 inhibitor discontinuation is the most significant independent predictor of stent thrombosis. • Current recommendations for dual antiplatelet therapy are the following: it is needed for at least 2 weeks after balloon angioplasty without stenting, for at least 6 weeks after bare-metal stent placement, and for at least 1 year after drug-eluting stent placement.

6. However, in the perioperative patient the risk of bleeding has to be weighed against the risk of thrombosis. In many situations the risk of coronary thrombosis is high and the consequences of coronary thrombosis could be catastrophic; on the other hand, although the risk of bleeding is increased, bleeding could be manageable and may not contribute to significant morbidity and mortality. In such cases it may be prudent to continue antiplatelet therapy. • However, some individuals are more prone to bleeding or need to undergo procedures in which bleeding can have severe consequences. These include neurosurgery, spinal cord decompression, aortic aneurysm surgery, and prostatectomy, among others. In such cases the risk of bleeding may outweigh the risk of thrombosis, so antiplatelet therapy should be stopped before these operations (at least 5 days before surgery for clopidogrel or ticagrelorand 7 days for prasugrel) and resumed as soon as feasible postoperatively.

7. Perioperative Management of Patients With Stents • Five factors should be considered when caring for a patient with a coronary stent: • (1) timing of the operation after PCI, also called the PCI-to-surgery interval, • (2) continuation of dual antiplatelet therapy, • (3) perioperative monitoring strategies, • (4) anesthetic technique, • (5) immediate availability of an interventional cardiologist.

9. Continuation of Dual Antiplatelet Therapy • Dual antiplatelet therapy should be continued for at least 6 weeks after bare-metal stent placement and 1 year after drug-eluting stent placement. • If dual antiplatelet therapy must be stopped, at least the aspirin portion of the therapy should be continued. • Aspirin should be stopped before elective surgery only when absolutely indicated. • In a bleeding patient, platelets can be administered to counteract the effects of antiplatelet drugs, but the effectiveness of the platelet infusions will depend on the timing of the last dose of antiplatelet drug.

10. Immediate Availability of an Interventional Cardiologist • Once the diagnosis of AMI or acute stent thrombosis is made or considered, triage to interventional cardiology within 90 minutes is strongly recommended. • Mortality increases substantially if reperfusion Is delayed .

11. Laboratory  • Troponin and brain natriuretic peptide • Other preoperative blood tests • Electrocardiogram

12. آقای ۷۰ ساله ای که ۶ ماه قبل تحت آنژیوگرافی و تعبیهDrug-Eluting stent قرارگرفته است. جهت انجام عمل جراحی هرنی اینگوینال به درمانگاه مراجعه نموده است. کدام اقدام را جهت وی انجام می دهید؟ • الف) به تاخیر انداختن عمل جراحی تا یکسال بعد از تعبیه stent • ب) قطع داروی کلو پیدوگرل یک هفته قبل از عمل جراحی • ج) قطع داروی آسپرین سه روز قبل از عمل جراحی • د) رزرو و تجویز پلاکت در صورت خونریزی حین عمل

13. آقای ۶۲ ساله جهت عمل جراحی هرنی به اتاق عمل آورده شده است. برای بیمار دو ماه قبل یک استنت bare metal در عروق کرونری راست گذاشته شده است .کدام یک از اقدامات زیر در این بیمار غلط می باشد • الف)Clopidogrelباید ۷ روز قبل عمل قطع شود • ب)بهتر است یک ماه عمل جراحی به تعویق بیفتد • ج) باید عمل جراحی در مرکزی که کاردیولوژی تهاجمی وجود دارد انجام شود • د) قطع آسپرین 5 روز قبل از عمل

14. آقای ۸۰ ساله مورد شناخته شده بیماری ایسکمیکقلبی و سابقه آنژیوگرافی و کارگذاری استنت فلزی در دو ماه گذشته تحت درمان دارویی کاندید عمل جراحی پروستات می باشد در کلینیک بیهوشی کدام یک از اقدامات زیر را توصیه می نماید • الف) عقب انداختن عمل جراحی به مدت حداقل ۴ ماه • ب) قطع آسپرین و ادامه سایر داروها و آماده سازی جهت عمل جراحی • ج) قطع پلاویکس و ادامه سایر داروها و آماده سازی جهت عمل جراحی • د) آماده سازی بیمار جهت عمل جراحی و توصیه ادامه همه دارو ها

15. ANESTHETIC GOALS  • Prevention of myocardial ischemia. • Detection of myocardial ischemia. • treatment of myocardial ischemia.

16. Prevention of ischemia  • Low to normal heart rate • Normal to high blood pressure • Normal left ventricular end-diastolic volume • Adequate arterial oxygen content • Normothermia

17. Monitoring for ischemia • Electrocardiography • Intra-arterial catheter • Central venous catheter • Pulmonary artery catheter • Transesophagealechocardiography

18. Treatment of ischemia  • Treat tachycardia • Treat hypertension • Treat hypotension • Maintain oxygen carrying capacity of the blood • Prevent and treat hypothermia

19. MANAGEMENT OF ANESTHESIA • Premedication • Selection of anesthetic technique  • Neuraxialregional anesthesia 

20. General anesthesia • Induction • Maintenance • Emergence

21. Management of arrhythmias  • Ventricular fibrillation • Atrial fibrillation • Bradycardia

22. POSTOPERATIVE MANAGEMENT • Monitoring for myocardial injury  • Management of pain 

24. THANK YOU