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Archives of Volume 1, Issue 1, 2018, PP: 8-16 Anesthesia and Cardiovascular Bhavna Gupta*, Lalit Gupta Maulana Azad Medical College and Loknayak , New Delhi-110002. [email protected] *Corressponding Author: Bhavna Gupta, Maulana Azad Medical College and Loknayak Hospital, New Delhi.

Abstract In this Review article, we have discussed the anesthesia considerations in a case of pre-existing cardiac disease. Successful anesthesia in these revolves around careful planning, team work, and perioperative formulation of plan, execution and management. Keywords: Anesthesia, .

Introduction An adrenergic surge leading to an imbalance in myocardial O supply-demand ratio. This in turn Administering anesthesia to patients with preexisting 2 causes ischemic myocardium. It is primarily cardiac disease is an challenge. Most common cause of peri-operative morbidity and mortality in cardiac patients is ischemic heart disease affecteda) Tachycardia by: (IHD). IHD is number one cause of morbidity and b) increased wall tension mortality all over the world.Successful perioperative c) increased preload management of ischemic heart disease patients undergoing non cardiac requires careful team d) increased after load work and communication between , primary e) increased myocardial contractility care , anesthesiologist and . • Myocardial Supply: Increase in oxygen requirement of myocardium can be met by intervention strategy, risks associated with non- In assessing the risks and benefits of a perioperative must be individualized. Therefore the anesthesiologist must exercise judgment to correctly increasing coronary blood flow. It can be affected • Decreased Coronary Blood Flow: which in turn assess perioperative surgical risks and the need for by: further evaluation.Care of these patients require isa. affectedTachycardia by following: which cause decrease in diastolic & optimization, medical , and the perfusion time identification of risk factors, pre-operative evaluation choice of appropriate anesthetic technique and drugs b. especially because of fall in Coronary Disease (Cad) diastolic BP c. Incrreased Pre load by causing decreased Prevention of myocardial ischemia during surgery perfusion pressure decreases the incidence of perioperative (MI). Optimizing oxygen delivery to the d. Hypocapnia by causing coronary myocardium is equally important for hemodynamic vasoconstriction management. e. Coronary Vasopasm

• Myocardial Oxygen Demand: The principal • Decreased Oxygen Content And Availability: determinants of myocardial oxygen demand a. Anemia are wall tension and contractility. The increase which in turn is affected by in during perioperative period causes. b. Hypoxia. Archives of Anesthesiology V1 . I1 . 2018 8 Anesthesia and Cardiovascular Disease Hemodynamic Goals 3. patients with cardiovascular disease include 1. Although the precise relationship between statinsPharmacologic and angiotensin-converting agents which may enzyme benefit intraoperative myocardial ischemia and (ACE) inhibitors (stabilize atherosclerotic postoperative MI remains controversial, plaques) and volatile (anesthetic there is consensus that a primary goal of a preconditioning). successful anesthetic is the prevention of myocardial ischemia. Monitoring for Ischemia 2. A well balanced approach of combination of A. The preferable monitoring technique (as per availability) for detecting myocardial ischemia anesthetics, agents, muscle relaxants and vasoactive agents are chosen to decrease myocardial oxygen requirements and decrease • involves:Electrocardiogram (Table-1) (ST segment analysis of leads the likelihood of myocardial ischemia. V5 and II) Table 1. Relation between areas of myocardial ischemia and ECG leads1

ECG leads Coronary artery Area of ischemia I, AVL Lateral aspect of left ventricle

II, III, AVF CircumflexRight coronary artery artery Right atrium, Right ventricle V3 - V5 Anterior descending artery Anterolateral aspect of left ventricle

• and (not a sensitive myocardial depression; ; and reliable predictor of myocardial ischemia) suppression of sympathetic nervous system responses to . Disadvantages include • myocardial depression, systemic hypotension, ischemia-induced papillary muscle dysfunction catheter (V waves reflect and lack of postoperative analgesia. • Transesophageal echocardiography (regional Combinations of and volatile anesthetics wall motion abnormalities are the most sensitive may produce the advantages of each with minimal indicator of myocardial ischemia)

Selection of Anesthesia anesthetic could be used as a balanced technique. undesirable side effects. It is likely that any volatile There is no ideal anesthetic agent of choice in patients with Ischemic Heart Disease. Choice of anesthetic is a coronary vasodilator (more so depends on the extent of pe existing myocardial than other volatile anesthetics), but this effect is alveolar concentration (MAC). There is no evidence dysfunction and pharmacological properties of clinically insignificant in doses below 1 minimum of an increased incidence of myocardial ischemia or specificI. Opioids drugs. such as in higher dosage in the worsened outcome.Desfluraneand possess range 50-100 µg/kg intravenously are preferred the advantage of faster recovery. A sudden increase in in severe myocardial dysfunction as they lack hemodynamic profiles similar to isoflurane but have increased plasma epinephrine concentration. good left ventricular function, opioids may be the inspired concentration of desflurane may result in myocardial effect. In patients with inadequate to depress sympathetic nervous Treatment of Ischemia system activity, requiring the addition of a Anesthetics or vasoactive drugs that enable the heart volatile anesthetic or vasoactive drug. to return to a slower rate, and well-perfused state are frequently essential during anesthesia. II. Inhalation anesthetics have the advantages of dose dependency; easily reversible, titratable a) Nitrates. Nitroglycerin is the drug of choice 9 Archives of Anesthesiology V1 . I1 . 2018 Anesthesia and Cardiovascular Disease for the treatment of coronary vasospasm. As a anxiety, assessment of vital signs, JVP pulsation, venodilator, this drug decreases venous return carotid bruit, and oedema. Investigations thus wall tension. and decreases ventricular filling pressures and 1. Haemogram b) Vasoconstrictors. Phenylephrine increases 2. myocardial oxygen requirements, but this increase 3. CardiacBlood glucose specific levels tests – ECG, ECHO produced by the increased coronary perfusion 4. Blood urea , Serum Creatinine is offset by improvements in oxygen delivery pressure. 5. LFT c) Supplemental Evaluation oxygen balance by preventing or treating β-blockers: β-blockade improves myocardial tachycardia and by decreasing contractility. Atenolol improves long-term survival in patients Done1. Resting in specific LV function situations. It includes: with heart disease undergoing noncardiac 2. Exercise/ Pharmacological Stress Testing surgery. 3. d) Calcium channel blockers are useful in slowing 4. AmbulatoryCoronary Angiography ECG monitoring 5. the ventricular response in atrial fibrillation treatment of perioperative hypertension. and flutter, as coronary vasodilators, and in the Ina. patientsExercise with Echo abnormal resting ECG LBBB,LVF) Preoperative Clinical Evaluation b. Exercise Myocardial perfusion imaging This includes history, , 6. investigation, clinical risk predictors, risk assessment, a. Dobutamine stress Echo and functional capacity. In patients who cannot exercise: b. Thallium Scintigraphy History Functional capacity 1. Exercise tolerance is assessed by history and is i. Angina at unaccustomed work. No limitation History of Angina: NYHA Grading expressed as metabolic equivalents (MET). (MET; 1 of physical activity ii. Angina on moderate exertion. Mild limitation Duke Activity Status Index in order to estimate the MET = 3.5 ml O2/kg/min) on a scale defined by the of physical activity patient’s maximal oxygen consumption capacity (Table 2). iii. Angina on mild exertion. Marked limitation of physical activity Patients with moderate or excellent functional capacity and low clinical predictors of risk do not need iv. Angina at rest. further cardiac investigation. The functional capacity 2. History of Dyspnea of some patients might be limited by other conditions 3. Oedema (e.g. Respiratory, peripheral vascular or joint disease). These patients and those with poor functional 4. History of Myocardial infarction capacity should undergo detailed cardiac assessment 5. Family History of CAD Preoperative coronary angiography 6. Current medications Indicated in certain conditions like patients with Physical Examination proven CAD, unstable angina, angina resistant to Look for cyanosis, pallor, dyspnea during conversation, medical therapy, urgent surgery in a patient resolving nutritional status, skeletal deformities, tremors & from acute MI. Archives of Anesthesiology V1 . I1 . 2018 10 Anesthesia and Cardiovascular Disease Table 2: Metabolic Equivalents2 MET (metabolic Estimated energy requirements for various activities equivalents) Poor functional Light housework capacity (1-4 MET) Shower or dress without stopping Walk at 2-3 mph on level ground Moderate functional capacity (5-7 MET) ClimbLight gardeninga flight of stairs without stopping Walk briskly (>4 mph) on flat Excellent functional Digging in garden capacity (>7 MET) Carrying shopping upstairs More strenuous sports (e.g. cycling uphill, jogging) Risk Assessment complications in patients with ischemic heart Several cardiac indices are used in clinical evaluation to predict postoperative cardiac diseaseA. (IHD: (Table3, 4) Table 3. Goldman Risk Index3,5 Goldman Multifactorial Cardiac Risk Index S.No. Cardiac risk variables Points Cardiac Rate 1 Third heart sound or jugular venous distension 11 2 Recent myocardial infarction 10 3 Nonsinus rhythm or premature atrial contraction 7

4 More than 5 premature ventricular contractions 7 0-5 points = 01% on ECG 5 Age more than 70 years 5 6-12 points = 07% 6 Emergency operations 4 13-25 points = 14% 7 Poor general medical condition 3 >26points = 78% 8 Intrathoracic, intraperitoneal or aortic operation 3 8 Aortic Stenosis 3 B. The Revised Cardiac Risk Index (RCRI) is another tool used to estimate a patient’s risk of the 2007 preoperative cardiac risk evaluation perioperative cardiac complications. Compared guidelineand was incorporated from the American in a modified Heart Association form into with the Original Cardiac Risk Index, the RCRI and American College of . The ACC/ was easier to use and more accurate. The RCRI AHA guidelines use the 5 clinical RCRI criteria in is used widely in clinical practice, research, their screening algorithm. Table 4. Revised Cardiac Risk Index4 Revised Cardiac Risk Index 1 History of ischemic heart disease 2 History of congestive heart failure 3 History of cerebrovascular disease (stroke or transient ischemic attack) 4 History of diabetes requiring preoperative insulin use 5 (creatinine > 2 mg/dL) 6 Undergoing suprainguinal vascular, intraperitoneal, or intrathoracic surgery Risk for cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest: 0 predictors = 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%, ≥3 predictors = >11%

11 Archives of Anesthesiology V1 . I1 . 2018 Anesthesia and Cardiovascular Disease Risk Stratification capacity and the type of surgery are then used to formulate A combination of various high risk factors, the functional

Low Risk Surgery Intermediate Risk Surgerya plan (figure1) forHigh further Risk decisionsurgery for surgery. No CAD markers 1-2 CAD markers >3 CAD markers Active Style drugs CAD: symptoms controlled on Major CAD: not controlled on drugs Age< 70 yrs Severe /poorly controlled LV drugs dysfunction LV dysfunction: well controlled on

Figure 1. Risk Stratification6, 7 Anesthetic Management 1. Optimization of medical management Preoperative Management 2. Revascularization by PCI or At risk patients need to be managed with pharmacologic and other perioperative interventions Optimization of Medical Management that can ameloriate perioperative cardiac events. 3. CABG Three therapeutic options are available before elective foundation for the use of beta blockers to prevent Many randomized controlled trials provide a firm nonArchives cardiac of surgery:Anesthesiology V1 . I1 . 2018 12 Anesthesia and Cardiovascular Disease perioperative ischemic events in high risk and Preoperative Coronary Revascularization Indicated in high risk CAD and in who long term would intermediate• risk patients for the reason that: cardiac death & MI and may decrease the need of Peri operative beta blockade significantly reduces likelyPercutaneous be improved Coronary by CABG Intervention(AHA/ACC 2007) revascularization before non-cardiac surgery. After balloon angioplasty to wait for 1 week for non- • Tight heart rate control with beta blockade dispenses the need for routine non invasive pre- Anesthesia Goals op testing (intermediate grade & prophylactic cardiac surgery and 4 – 6 weeks after coronary stent. coronary re-vascularisation in high risk patients. The primary goal of the anesthetic management of a patient with IHD for non-cardiac surgery is • avoidance of myocardial ischemia and infarction. beta selective agent with long life (bisoprolol) or a This is accomplished by preventing ischemia To achieve 24 hrsefficacies with once daily dosing formulation providing extended plasma through measures that improve the myocardial o2 concentration (metaprolol succinate) is supply demand balance, primarily by controlling the suggested. patient hemodynamics and by detecting and treating myocardial ischemia when it occurs. • on cardiac complications during non- cardiac There is a protective effect of perioperative statins surgery. (2007 AHA/ACC) Preoperatively patient should be explained the risk • It is reasonable to start bisoprolol 2.5 mg daily or of surgery &anesthesia. The premedication should prevent increase in B.P and H.R which can disturb metaprolol 25-50 mg daily. These drugs should myocardial O supply and demand and can induce be started 30 days prior to surgery. 2 ischemia. Any combination of and To summarize various recommendations from many like should be given an hour prior to arrival in O.T trials:1. To add or continue, beta blockers in high risk and Intraoperative Management intermediate risk patients titrated to HR of 50 Incidence of ischemia is low in the intraoperative period as compared with pre and post operative period. 2. –60/mtAlpha 2 agonists by virtue of their sympatholytic Monitoring blockers are contraindicated. effects can be useful in patients where beta 1. 3. Other agents like calcium channel blockers, ACE detects M.I in the distribution of LAD ECG: 5 lead ECG will be useful.V5 leads inhibitors, aspirin insulin & statins prove to be Lead II detects M.I in the distribution of RCA and also . The ST Segment trending also helps in the detection of ischemia. 4. beneficialTo continue peri-operatively drugs like beta blockers,anti- 2. Pulse oximetry, ETCO2, urine output, temp hypertensives (except ACE inhibitors) digitalis, monitoring, NIBP Ca2+ blockers till the day of surgery 3. Intra-arterial cannulation 5. NSAIDS should be discontinued 1 week prior to elective procedures. 4. 6. Most can be performed safely at an INR 5. CVPPulmonary – essential artery in all catheter except minor and cardiacprocedures. output <1.5 (indicated in intrathoracic or abdominal vascular

7. Stop warfarin 5 days before and LMWH 12-24 40% or if PHT is present). hours prior. surgeries as a guide for fluid management, if EF < 6. 8. Stop clopidogrel at least 5 days before surgery. for routine use. Esophageal Stethoscope and TEE: not advocated 13 Archives of Anesthesiology V1 . I1 . 2018 Anesthesia and Cardiovascular Disease Choice of Anesthesia Short acting opioids are preferred for maintenance of anesthesia The anesthesiologist should select drugs with the object of minimizing demand and supply of oxygen. • of choice is VECURONIUM Along with the anesthetic agents, cardiac drugs should because of its minimal hemodynamic alterations be readily available to maintain hemodynamics to prevent and treat ischemia if it occurs. •

General Anesthesia higherIsoflurane MAC is dosage acceptable of volatile volatile agent anesthetic, limits the sevoflurane or desflurane are acceptable, 0.5 or Preoxygenation for 3-5 minutes is must. extent of myocardial if MI occurs. Induction • drugs preferred include morphine, fentanyl, alfentanyl and sufentanyl

In patients with good LV function, Induction with • Ideal Hemodynamic status include a lower fentanylInduction and should thiopental have minimal or hemodynamic can be preferred. effects. heart rate, normal blood pressure and adequate Fentanyl is given in doses of 2-3 mcg/kg prior to coronary perfusion pressure. induction with propofol or etomidate. Reversal • Propofol 2-2.5 mg/kg is preferred if Systolic BP (SBP) more than 125 mmHg and Etomidate 0.2 atropineAccomplished since it withproduces Neostigmine less tachycardia. &Glycopyrrolate between 110-125 mm Hg either low dose propofol in normal doses.Glycopyrrolate is preferred over ormg combination – 0.3mg/kg if of SBP propofol is 110 and or less.etomidate For SBP or Intraoperative Ischemia etomidate alone is preferred. • Thiopentone- reduces myocardial contractility, preload and blood pressure with slight increase ECG criteria for diagnosis of ischemia in anaesthetized  in HR. Administer slowly in doses of 3-5 mg/kg patients include: msec after J point with caution. Upsloping ST segment : 2mm depression, 80  • m sec after J point induction is preferred. Horizontal ST segment : 1mm depression 60 – 80 In Patients with LV Dysfunction: High dose opioids  Muscle Relaxants curve to PQ junction • Vecuronium produces minimum hemodynamic Downloading ST segment : > 1mm from top of  ST elevation alterations and is short acting, therefore suitable for use in cardiac patients. Rocuronium is newer  T wave inversion non depolarizing muscle relaxants without any Treatment  • significant cardiovascular side effects. with 2% 1.5 mg/kg lignocaine 90 seconds Sinus Tachycardia – Propranolol 1mg / Esmolol Obtundation of Response: Achieved continuous) /metoprolol up to 15 mg before intubation. has to be done 100 – 500 mcg/kg -1mg/kg (intermittent or after good relaxation of jaw muscles. Cords are  Hypertension - deepening anesthesia/Vasodilators sprayedwith 2 cc of 2% lignocaine and intubated with well lubricated endotracheal tubes to prevent 5-10 mg sympathetic surge. – NTG 1mcg/kg/min/ Labetolol – (intermittent)  Maintenance of Anesthesia Inotropes Hypotension – Vasoconstrictor/Volume ingestion/ • Patients with Normal LV function- O2+  N2O+Volatile anesthetics and muscle Heparin relaxants Ischemia – A) stable – beta blockers/IV NTG/ B) Unstable- Inotropes/IABP/Earliest possible • Patients with COMPROMISED LV FUNCTION- cardiac catheterization

Archives of Anesthesiology V1 . I1 . 2018 14 Anesthesia and Cardiovascular Disease Post-Operative Management Conclusion The period after surgery is associated with increased Patients with cardiac disease are presented for levels of catecholamine’s and hypercoagulability. anaesthesia for non cardiac surgery more frequently because of better screening and treatment modalities therefore, the preoperative plan should include the available with advancement of medical science and Most perioperative infarcts occur in the first 3 days; most appropriate place for postoperative care, and the anaesthesia. Since their perioperative courses are same management goals should be adhered to in this associated with greater morbidity and mortality, it is important to provide a hemodynamically stable for at least 72 hours after major surgery. Postoperative anaesthesia best suited for altered physiology of period. All patients should receive humidified oxygen, analgesia should be adequate.The patient’s normal diseased cardiovascular system. cardiac medication should be restarted as soon as possible. The goals in immediate postoperative This requires in-depth knowledge of the of the disease, and of the drugs periods1. Prevent must ischemia be: Meticulous preoperative screening and therapy with 2. Monitor for MI and procedures with their effects on the patient. of intraoperative hemodynamics monitoring, 3. Treat M.I postoperativebeta blockers or analgesia α-2 agonist with and epidural careful maintenance or PCA and continuous post op monitoring are key for better hours. outcome in these patient. 4. Continuous ECG monitoring – for the first 36 – 72 5. Temperature control References 6. Maintenance of hemodynamic status [1] General Anesthesia vs Regional Anesthesia Mirvis DM, Goldberger AL. . Cardiovascular , 9th edition, Bonow RO, Regional Anesthesia (RA) is a good choice in In: Braunwald’s Heart Disease: A Textbook of intermediate and low risk surgeries and in procedures Mann DL, Zipes DP, Libby P (Eds), W.B. Saunders involving extremities, the perineum and lower Company, Philadelphia 2011 [2] Royall, Penelope Slade; Troiano, Richard P.; pressures and reduces myocardial wall tension. . RA is acceptable as it causes low filling Johnson, Melissa A.; Kohl, Harold W.; Fulton, Janet Epidural anesthesia reduces preload and afterload, coagulation responses, and in the case of thoracic Evidence about Total Amount and Intensity of E. (2008). “Appendix 1. Translating Scientific epidural analgesia may reduce the incidence of tachycardiaepidurals, causes arising coronary due to vasodilatation. postoperative Good . Physical Activity into Guidelines”. 2008 Physical Department of Health and Human Services. pp. However, the hypotension which follows the regional Activity Guidelines for Americans. United States anesthesia if severe and rapid may reduce the coronary [3] 54–7. Multifactorial index of cardiac risk in noncardiac infusionperfusion or pressure vasopressors & blood like flow. Any fall (if in associated BP below Goldman L, Caldera DL, Nussbaum SR, etal. with20% bradycardia)baseline should or phenylephrine. be promptly treated with fluid 1977. In a patient with IHD, techniques surgical procedures. N. Engl J Med. 297:845, [4] Lee, T. H.; Marcantonio, E. R.; Mangione, C. such as should be M.; Thomas, E. J.; Polanczyk, C. A.; Cook, E. F.; encouraged in order that the hemodynamic Sugarbaker, D. J.; Donaldson, M. C.; Poss, R.; responses to general anesthesia are avoided. Trying to cover for a patchy or incomplete block with excessive or other methods defeats (1999). “Derivation and prospective validation Ho, K. K.; Ludwig, L. E.; Pedan, A.; Goldman, L. very purpose of selecting regional anesthesia. In of a simple index for prediction of cardiac risk of anesthesia as soon as feasible. such cases it is advisable to convert to General major noncardiac surgery”. Circulation. 100 (10): Archives of Anesthesiology V1 . I1 . 2018 15 1043–1049. Anesthesia and Cardiovascular Disease [5] [11] of patients with known or suspected coronary cardiovascular evaluation of the intermediate- Mangano DT, Goldman L. Preoperative assessment Wesorick DH, Eagle KA: The preoperative 1756. disease. N Engl J Med. 1995; 333(26):1750– risk patient: new data, changing strategies. Am J [6] [12] Med 2005; 118:1413. Fleisher LA, Barash PG. Preoperative cardiac the cardiac risk of noncardiac surgery. Circulation Auerbach A, Goldman L: Assessing and reducing evaluation for noncardiac surgery: a functional [7] approach. Anesth Analg. 1992; 74(4):586–598. Cardiovascular Evaluation for Noncardiac [13] 2006; 113:1361-1376. Eagle KA et al. Guidelines for Perioperative Perioperative myocardial infarction. Circulation. Landesberg G, Beattie WS, Mosseri M,et al. [8] Surgery. Circulation 1996; 93: 1278-1317. [14] 2009; 119(22):2936–2944. cardiacGordon AJ, assessment. Macpherson Am DS. J Guideline Cardiol. chaos: 2003; cardiovascular assessment and management. conflicting recommendations for preoperative 2014 ESC/ESA Guidelines on non-cardiac surgery: [15] Fleisher LA, Fleischmann KE, Auerbach AD, et [9] 91(11):1299–1303. Cardiovascular Evaluation and Care for al. 2014 ACC/AHA guideline on perioperative “ACC/AHA 2007 Guidelines on Perioperative cardiovascular evaluation and management Journal of the American College of Cardiology. 50 Noncardiac Surgery: Executive Summary”.

[10] Stoelting RK, Dierdorf S. Ischemic heart of patients undergoing non cardiac surgery: (17): 1707–1732. College of Cardiology/American Heart executive summary: a report of the American Anesthesia and co-existing disease. 4th edition. Association Task Force on practice guidelines. J Philadelphiadisease. In: . Stoelting Churchill RK,Livingstone Dierdorf 2002. S, editors.

Nucl Cardiol. 2015; 22(1):162–215.

Citation: Bhavna Gupta, Lalit Gupta. Anesthesia and Cardiovascular Disease. Archives of Anesthesiology. 2018; 1(1): 8-16. Copyright: © 2018 Bhavna Gupta, Lalit Gupta. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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