Ischemic Heart Disease

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Ischemic Heart Disease
2015-09-03 20:23:39
Anesthesia Ischemic Heart Disease

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  1. Coronary Artery Atherosclerosis Risk Factors
    • Age
    • Male
    • Hypercholesterolemia
    • HTN
    • Cigarettes
    • Diabetes
    • Sedentary Lifestyle
    • Family Hx
  2. Angina Pectoris
    • Imbalance of O2 supply/demand
    • Adeonsine and Bradykinin Release: slows AV conduction and decreases contractility
    • ECG: ST depression and possible T-wave inversion (Variant angina may show ST elevation)
  3. Antiplatelet Drugs
    • Aspirin: COX inhibitor
    • Clopidogrel (Plavix) & ticlopidine (Ticlid): ADP Receptor Blockers (inhibit platelet aggregation)
    • Abciximab, eptifibatide, tirofiban: Platelet glycoprotein IIb/IIIa receptor antagonist (inhibit platelet adhesion, activation, and aggregation)
  4. Beta-Blockers
    • Principal drug for angina pectoris
    • B1-block decreases rate and contractility
    • May mask hypoglycemia in DM
    • Contraindicated: bradycardia, sick sinus syndrome, severe reactive airway, AV heart block, and uncontrolled CHF
  5. Ca Channel Blocker
    • Tx angina pectoris due to coronary artery vasospasm
    • Decrease vascular smooth muscle tone, dilate coronary arteries, decrease myocardial contractility/O2 consumption, and decrease arterial pressure. 
    • Contra: CHF
  6. Nitrates
    • Dilate coronary arteries/collateral BVs and decrease peripheral vascular resistance (decrease LV after load and O2 consumption)
    • Contra: Within 24 hours of sildenafil (Viagra), hypertrophic obstructive cardiomyopathy, and severe aortic stenosis
  7. ACE Inhibitors
    • Inhibits Angiotensin II formation (&bradykinin breakdown) which can lead to myocardial hypertrophy, interstitial myocardial fibrosis, increased coronary vasoconstriction, and endothelial dysfunction.
    • Tx: heart failure and HTN
    • CI: allergy, hyperkalemia (-aldosterone), bilateral renal artery stenosis, and renal failure.
  8. Acute Coronary Syndrome
    • Hyper coagulable state w/ focal disruption of an atherosclerotic plaque & artery occlusion. 
  9. ST Elevated Myocardial Infarction (STEMI)
    • Occurs when coronary blood flow decreases abruptly due to acute thrombus formation when a atherosclerotic plaque fissures, ruptures, or ulcerates. 
    • Dx: 1.Chest pain, 2.serial ECG changes indicative of MI, 3.Increase and decrease of serum cardiac enzymes. 
    • Differential: PE, aortic dissection, spontaneous pneumothorax, pericarditis, cholecystits
    • Tx: 1. evaluate hemodynamic stability, 2. 12 lead EKG, 3. Oxygen, 4. Pain relief (IV morphine or SL NTG), 5. Aspirin/Clopidogrel, 6. Reestablish flow and decrease further thrombus formation 
    • Adjuctive: Beta-Blockers, IV heparin, ACEi, ARBs
  10. Unstable Angina (UA)/ Non-ST Elevation Myocardial Infarction (NSTEMI)
    • Results from reduction in myocardial O2 supply due to rupture or erosion of an atherosclerotic coronary plaque leading to thrombosis, inflammation, and vasoconstriction (<50% stenosis). 
    • Dx: 1. Angina at rest, 2. Chronic angina pectoris that becomes more frequent and easily provoked, 3.New-onset angina
    • Adjuncts: Hemodynamic instability or CHF (S3 gallop, jugular venous distention, pulmonary rales, peripheral edema), ST depression, deep/symmetrical T-wave inversions
    • Tx:1. Bed rest, 2. Supplemental O2, 3. analgesia, 4.Beta blocker, 5. SL NTG, 6. Aspirin/clopidogrel & 48 hours of IV heparin
  11. Complications of Acute MI (Cardiac Dysrhythmias)
    • Ventricular fibrillation: defibrillation, amiodarone, B-blockers
    • Ventricular tachycardia: electrical cardioversion, IV lido, amiodarone
    • Atrial fibrillation: cardioversion, B-blocker, Ca channel blocker
    • Bradydysrhythmias/Heart Block: atropine or pacemaker if hemodynamic compromise.
  12. Complications of Acute MI (List)
    • Cardiac Dysrhythmias
    • Pericarditis
    • Mitral Regurgitation
    • Ventricular Septal Rupture
    • Congestive heart failure/Cardiogenic Shock
    • Myocardial Rupture
    • RV Infarction
    • Cerebrovascular Accident
  13. Complications of Acute MI: Pericarditis
    • Pain gets worse w/ inspiration or lying down
    • Friction rub sound
    • Tx: Aspirin/indomethacin (NSAID), corticosteroids,
  14. Complications of Acute MI: Mitral Regurgitation
    • Likely after inferior wall MI
    • Results in pulmonary edema and cariogenic shock
    • Tx: nitroprusside (decrease LV afterload)
  15. Complications of Acute MI: CHF and Cardiogenic Shock
    • Cardiogenic Shock: A form of acute heart failure where hypotension and oliguria persist and CO is insufficient to perfuse organs. 
    • Tx: NE, vasopressin, dopamine, or dobutamine to improve BP/CO, NTG in the presence of adequate BP (decrease LV preload/afterload), morphine, diuretics or mechanical ventilation w/ pulmonary edema
  16. Complications of Acute MI: RV Failure
    • Clinical Triad: hypotension, increased jugular venous pressure, and clear lung fields
    • Undesirable drugs: vasodilators and diuretics
    • Tx: dopamine (+inotropic) for hypotension, AV pacing (3rd degree Block), IV fluids,
  17. Preoperative: Ischemic Heart Disease
    • S/S: myocardial ischemia, LV dysfunction, cardiac dysrhythmias
    • Delay elective Sx at least 6 weeks and 12 months w/drug-eluting stent
    • Co-existing Diseases: Peripheral vascular disease, orthopnea, paroxysmal nocturnal dyspnea, syncope, diabetres mellitus, renal insufficiency,
  18. Ischemic Heart Disease Medications
    • Decrease O2 demand, improve coronary blood flow, stabilize plaque, prevent thrombosis, and remodel the injured myocardium
    • Beta Blockers: esmolol, atenolol, metoprolol
    • Nitrates: NTG
    • Ca Channel Blockers: nicardipine
    • Statins: Simvastatin, 
    • Anti-platelets: aspirin (COX), clopidogrel (ADP), GlyIIb/IIIa inhibitors (abciximab)
    • ACE Inhibitors: Lisinopril, discontinue prior to surgery
  19. Predictors of Major Cardiac Complications
    • High risk Surgery
    • Ischemic Heart Disease
    • Congestive Heart Failure
    • Cerebrovascular disease
    • Preoperative insulin-dependent diabetes mellitus
    • Serum Creatinine >2.0mg/dl
  20. Major Clinical Risk Factors: Cardiac
    • Unstable Coronary Syndrome
    • Decompensated Heart Failure
    • Significant Arrhythmias
    • Severe Valvular Disease
  21. Intermediate Clinical Risk Factors: Cardiac
    • Stable Angina
    • Previous MI (Hx or Pathologic Q waves)
    • Compensated or previous heart failure
    • Insulin-dependent diabetes mellitus
    • Renal insufficiency
  22. Minor Clinical Risk Factors: Cardiac
    • HTN
    • LBBB
    • Non-specific ST T-wave changes
    • History of Stroke
  23. Intraoperative Events That Decrease Myocardial O2 Delivery
    • Decreased Coronary Blood Flow
    • Tachycardia
    • Diastolic Hypotension
    • Hypocapnia (coronary aftery vasoconstriction)
    • Coronary Artery Spasm
    • Decreased Oxygen Content
    • Anemia
    • Arterial hypoxemia
    • Shift of the O2-Hb curve to the left
  24. Intraoperative Events that Increase Myocardial  O2 Requirement
    • Sympathetic Nervous System Stimulation
    • Tachycardia
    • Hypertension
    • Increased Myocardial Contractility
    • Increased Afterload
    • Increased Preload
  25. Drugs to Blunt Sympathetic Response to Tracheal Intubation
    • Lidocaine (IV/Laryng)
    • Esmolol
    • Fentanyl
  26. Maintenance of Anesthesia
    • Normal LV Function: Volatile anesthetics
    • Impaired LV function: opioids + N2O, benzos, low-dose volatiles
  27. Transplanted Heart
    • No sympathetic, parasympathetic, or sensory innervation, resulting in high resting HR
    • Carotid massage and Valsalva maneuver have no effect on HR
    • No sympathetic response to DL and tracheal intubation
    • Response to hypotension/hypovolemia through an increase in SV (Frank-Starling)
    • Alpha and Beta adrenergic receptors are still intact.