Anesthesia for noncardiac surgery in patients with ischemic heart disease
- Nadia Blakemore Hensley, MD
Nadia Blakemore Hensley, MD
- Assistant Professor, Department of Anesthesiology and Critical Care Medicine
- The Johns Hopkins University School of Medicine
- Charles W Hogue, MD
Charles W Hogue, MD
- James E. Eckenhoff Professor of Anesthesiology
- Northwestern University Feinberg School of Medicine
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 emergent surgery.
This topic will review the preanesthesia consultation, anesthetic care, and immediate postoperative management of patients with ischemic heart disease having elective, urgent, or emergent noncardiac surgery. Anesthetic management of patients with ischemic and nonischemic heart failure is discussed in detail separately (see "Anesthesia for noncardiac surgery in patients with heart failure"). Preoperative medical evaluation and management of patients with known or suspected ischemic heart disease is addressed elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Management of cardiac risk for noncardiac surgery".)
Evaluation and management of cardiac risk
General considerations — All patients with ischemic heart disease scheduled to undergo noncardiac surgery should be assessed for the risk of a perioperative cardiovascular event [1,2]. Risk is related to both the type of surgical procedure (table 1) and individual patient factors (algorithm 1). (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Management of cardiac risk for noncardiac surgery".)
High cardiac risk — The following factors place the patient at high risk for a perioperative cardiovascular event. If possible, urgent consultation with a cardiologist should be obtained for acute preoperative and subsequent postoperative medical management.
Urgent or emergent surgery — Patients with ischemic heart disease who require any urgent or emergent surgical procedure are at higher risk for cardiovascular complications compared with those undergoing elective surgery, regardless of the severity of coronary artery disease and baseline risk. (See "Management of cardiac risk for noncardiac surgery", section on 'Patients who need urgent or emergent surgery'.)
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- PREANESTHESIA CONSULTATION
- Evaluation and management of cardiac risk
- - General considerations
- - High cardiac risk
- Urgent or emergent surgery
- Recent myocardial infarction or unstable angina
- Recent percutaneous coronary intervention
- Preoperative medication management
- Management of implantable cardioverter defibrillators and pacemakers
- ANESTHETIC GOALS
- Prevention of ischemia
- Monitoring for ischemia
- Treatment of ischemia
- MANAGEMENT OF ANESTHESIA
- Selection of anesthetic technique
- Local anesthesia with monitored anesthesia care
- Neuraxial regional anesthesia
- General anesthesia
- - Induction
- - Maintenance
- - Emergence
- Management of arrhythmias
- Control of glucose
- POSTOPERATIVE MANAGEMENT
- Monitoring for ischemia
- Management of pain
- SUMMARY AND RECOMMENDATIONS