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[Myocardial ischemia and anesthesia]
J J Lehot1, C C Arvieux, J P Viale
1Service d'Anesthésie-Réanimation, Hôpital Cardio-Vasculaire et Pneumologique, BP Lyon-Montchat.
Insights
Patients with coronary artery disease face high perioperative risks, including silent myocardial ischemia (MI). Early detection and prevention strategies are crucial for improving cardiac outcomes and reducing long-term adverse events.
Area of Science:
- Cardiology
- Anesthesiology
Context:
- Patients with coronary artery disease (CAD) are at increased risk for perioperative cardiac events.
- Perioperative myocardial infarction (MI) is a significant predictor of long-term adverse cardiac outcomes.
- Current methods for detecting perioperative MI have limitations in sensitivity and specificity.
Purpose:
- To discuss the challenges in detecting perioperative myocardial ischemia (MI).
- To outline a pragmatic approach for preventing and managing perioperative MI in patients with CAD.
- To consider the role of various interventions, including myocardial revascularization, antianginal agents, anesthetic techniques, and hemodynamic management.
Summary:
- Perioperative MI is a serious concern in patients with coronary artery disease, often preceded by silent ischemia.
- Detection of perioperative MI is challenging due to limitations in current monitoring technologies.
- A multifaceted approach involving preoperative revascularization, perioperative antianginal therapy, and management of hemodynamic factors like tachycardia and hypotension is proposed.
- Specific interventions like clonidine, anesthetic techniques, and normovolemic hemodilution are considered.
- Postoperative factors such as increased oxygen demand and pain can exacerbate cardiac risks, necessitating careful management.
Impact:
- Improved perioperative cardiac outcomes for patients with coronary artery disease.
- Reduced incidence and duration of perioperative myocardial ischemia (MI).
- Enhanced understanding of risk factors and preventive strategies for perioperative cardiac events.
Abstract:
Patients with coronary artery disease are particularly at risk perioperatively, as myocardial infarction, unstable angina, severe arrhythmia and cardiac death may occur. These events are often preceded by prolonged silent myocardial ischaemia (MI). Moreover, perioperative MI predicts long-term adverse cardiac outcome. Therefore, it is logical to prevent and treat MI. However, the detection of perioperative MI is difficult because of low sensitivity of ST-segment monitoring, low specificity of echocardiography and insufficient availability of equipment for its monitoring. A pragmatic approach is described, including preoperative consideration of myocardial revascularization prior to non-cardiac surgery and perioperative administration of antianginal agents; the effects of clonidine are discussed as well. The role of anaesthetic techniques and normovolaemic haemodilution is considered. MI episodes may be prevented or their duration may be shortened by treating tachycardia, hypotension and, possibly, hypertension. The risks of MI are particularly high during the postoperative period because increased global oxygen consumption associated with recovery, ventilator weaning, shivering and pain may lead to tachycardia and increased ventricular load. These factors must be taken into account in order to prevent MI and improve postoperative cardiac outcome.