The term ischemic heart disease (IHD) describes a group of clinical syndromes characterized by myocardial ischemia, an imbalance between myocardial blood supply and demand. Because the fundamental pathophysiologic defect in the ischemic myocardium is inadequate perfusion, ischemia is associated not only with insufficient oxygen supply, but also with reduced availability of nutrients and inadequate removal of metabolic end products. Ischemic heart disease (IHD) caused by atherosclerosis of the epicardial vessels leading to coronary heart disease (CHD) is the main etiology of IHD. Leading cause of death Resulting from myocardial ischemia—an imbalance between the supply (perfusion) and demand of the heart for oxygenated blood.  90% of cases, the cause of myocardial ischemia is reduced blood flow due to obstructive atherosclerotic lesions in the coronary arteries. IHD is often termed coronary artery disease (CAD) or coronary heart disease. There is a long period (up to decades) of silent, slow progression of coronary lesions before symptoms appear. IHD are only the late manifestations of coronary atherosclerosis that may have started during childhood or adolescence   Myocardial infarction, the most important form of IHD, in which ischemia causes the death of heart muscle. Angina pectoris, in which the ischemia is of insufficient severity to cause infarction, but may be a harbinger of MI. Chronic IHD with heart failure. Sudden cardiac death.  The dominant cause of the IHD syndromes is insufficient coronary perfusion relative to myocardial demand, due to • Chronic, progressive atherosclerotic narrowing of the epicardial coronary arteries, and • Variable degrees of superimposed acute plaque change, thrombosis, and vasospasm  Clinical manifestations of coronary atherosclerosis are generally due to • Progressive narrowing of the lumen leading to stenosis (“fixed” obstructions) or • Acute plaque disruption with thrombosis, both of which compromise blood flow. A fixed lesion obstructing 75% or greater of the lumen is generally required to cause symptomatic ischemia precipitated by exercise (most often manifested as chest pain, known as angina) Obstruction of 90% of the lumen can lead to inadequate coronary blood flow even at rest.

1. ANESTHESIA FOR
ISCHEMIC HEART DISEASE
BY: SUJATA WALODE, MSc OT & AT, MGM SBSA

2. ISCHEMIC HEART DISEASES
 The term ischemic heart disease (IHD) describes a
group of clinical syndromes characterized by
myocardial ischemia, an imbalance between
myocardial blood supply and demand.
 Because the fundamental pathophysiologic defect
in the ischemic myocardium is inadequate perfusion,
ischemia is associated not only with insufficient
oxygen supply, but also with reduced availability of
nutrients and inadequate removal of metabolic end
products.

3. 1. Ischemic heart disease (IHD) caused by atherosclerosis of the epicardial vessels leading to coronary heart
disease (CHD) is the main etiology of IHD.
2. Leading cause of death
3. Resulting from myocardial ischemia—an imbalance between the supply (perfusion) and demand of the
heart for oxygenated blood.
4. 90% of cases, the cause of myocardial ischemia is reduced blood flow due to obstructive atherosclerotic
lesions in the coronary arteries.
5. IHD is often termed coronary artery disease (CAD) or coronary heart disease.
6. There is a long period (up to decades) of silent, slow progression of coronary lesions before symptoms
appear.
7. IHD are only the late manifestations of coronary atherosclerosis that may have started during childhood
or adolescence
8. Myocardial infarction, the most important form of IHD, in which ischemia causes the death of heart
muscle.
9. Angina pectoris, in which the ischemia is of insufficient severity to cause infarction, but may be a
harbinger of MI.
10. Chronic IHD with heart failure.
11. Sudden cardiac death.
12. The dominant cause of the IHD syndromes is insufficient coronary perfusion relative to myocardial
demand, due to • Chronic, progressive atherosclerotic narrowing of the epicardial coronary arteries, and •
Variable degrees of superimposed acute plaque change, thrombosis, and vasospasm
13. Clinical manifestations of coronary atherosclerosis are generally due to • Progressive narrowing of the
lumen leading to stenosis (“fixed” obstructions) or • Acute plaque disruption with thrombosis, both of
which compromise blood flow.
14. A fixed lesion obstructing 75% or greater of the lumen is generally required to cause symptomatic
ischemia precipitated by exercise (most often manifested as chest pain, known as angina)

4. Risk Factors of Ischemic Heart Disease
A. Modifiable
1. Smoking
2. Cholesterol:
1. elevated LDL
2. low HDL (<40 mg/dl)
3. Arterial hypertension
4. Diabetes mellitus
5. Physical inactivity
6. Dietary factors:
1. PUFA deficient diets
2. Low Vitamin C and E
7. Obesity (BMI ≥30 kg/m2)
8. Stress factors
9. Fibrinogen and factor VII
B. Non-modifiable
1. Family history of premature CAD
1. <55 yrs for male
2. <65 yrs for female
2. Age and gender:
1. Male ≥ 45 years
2. Female ≥ 55 years
3. Genetic factors: operate in hyperlipidemia, plasma fibrinogen concentration and other coagulation factors, some of which are modifiable by
lifestyle changes

5. MEDICATIONS
 A number of different medications can also be used to treat a heart
attack:
• Blood thinners, such as aspirin, are often used to break up blood
clots and improve blood flow through narrowed arteries.
• Thrombolytics are often used to dissolve clots.
• Antiplatelet drugs, such as clopidogrel, can be used to prevent new
clots from forming and existing clots from growing.
• Nitroglycerin can be used to widen your blood vessels.
• Beta-blockers lower your blood pressure and relax your heart muscle.
This can help limit the severity of damage to your heart.
• ACE inhibitors can also be used to lower blood pressure and
decrease stress on the heart.
• Pain relievers may be used to reduce any discomfort you may feel.
• Diuretics can help decrease fluid buildup to ease the workload of the
heart

6. IHD
 In a patient of MI elective surgery should be deferred for
6 months because incidence of perioperative
reinfarction is 30-40%
 If time elapsed after previous attack of myocardial
ischemia is less than 3 months. It is 15% if time elapsed
is 3 to 6 months. Even after 6 months incidence is as
high as 6%
 Duration of surgery is important as more than 3 hours
can increase 6-16% incidence of reinfarction
 Post pone of surgery for 6 months is only for low risk
cases, i.e. only angina(no infarction), no h/o of CHF, no
h/o of DM, minor surgery, normal LVEF, normal renal
function.

7. Anesthesia
(PSE)
 ECG to detect LVEF is the most important
investigation.
 Aspirin need not be stopped except for plastic &
retinal surgeries.
 Clopidogrel should be stopped 7 days prior.
 All antianginal drugs to be continued.

8. MONITORING
 ECG is mandatory. Lead V5 is best to diagnose LVI
and lead II for arrythmia. Both combination can detect
94-95% of intraop ischemic events.
 Invasive CVP or BP – large intrabascular fluid shifts
are expected
 Pulmonary Artery catheterization – Extreme situations
 TEE- continuous assessment of intraoperative left
ventricular function. It can detect more than 99% of
ischemic events by abnormal motion but as it is
expensive its not used as routine monitor.

9. TYPES OF ANESTHESIA
 GA is preferred over SA/EA as hypotension associated with spinal
may not be tolerated. If it is given maintenance of BP is very
important.
 Premedication- Stress can induce MI. Benzodiazepines be given to
keep the patient calm.
 Induction- CVS response to laryngoscopy and intubation should be
blunted by lignocaine, Esmolol, opioids. Tachycardia is not accepted.
Choice of drug is ETOMIDATE.
 Maintenance- O2+N20(mild sympathetic stimulations)+Opioids
 Inhalational agents can depress CO but patient left ventricular
function is normal, inhalational agent can be used. Desflurane,
Sevoflurane, Isoflurane can be used.
 MR- Vecuronium(cardiac stable)
 Hypercapnia should be avoided as it can cause coronary
vasoconstriction.
 Reversal- Glycopyrolate +Neostigmine

10. Treatment
 NTG IV
 B Blockers
 Calcium channel blockers
 Heparin
 Intra Aortic Balloon pump (IAP)
 Correction of hemodynamic abnormalities.