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Indian Journal of Anaesthesia 2007; 51 (4) : 280-286

Indian Journal of Anaesthesia, August 2007

Anaesthetic Considerations in Cardiac Patients Undergoing Non


Cardiac Surgery
Tej K. Kaul1 , Geeta Tayal2
Key words

Peri-operative anaesthesia care, Cardiac diseases, Non cardiac surgery

Introduction
Administering anaesthesia to patients with preexisting cardiac disease is an interesting challenge. Most common cause of peri-operative morbidity and mortality in
cardiac patients is ischaemic heart disease(IHD). IHD
is number one cause of morbidity and mortality all over
the world1. Among the estimated 25 million patients in the
United States who undergo surgery each year, approximately 7 million are considered to be at high risk of IHD.
Indian figures are not available.Goldman et al reported
that 500,000 to 900,000 MIs occur annually worldwide
with subsequent mortality of 10-25%.Care of these patients require identification of risk factors, pre-operative
evaluation & optimization, medical therapy, monitoring and
the choice of appropriate anaesthetic technique and drugs.

intervention is indicated irrespective of the perioperative


context. No test should be performed unless it is likely
to influence patient treatment.

Evaluation
Patients having any sort of cardiac ailment need to
be evaluated properly preoperatively 6.

History
History elicits the severity, progression and functional limitation introduced by cardiac disease. History
should include:-.
1.

Exercise tolerance :- It depicts the cardiac reserve.It


can be Excellent -history of participation in sports like
swimming, football, tennis, basket-ball, skating etc.
Adequate-patient able to climb stairs, run a short distance. Poor- able to do leisure activities only e.g. slow
ballroom dancing or can walk around in the house only.

2.

Angina pectoris:-It is the symptomatic manifestation


of myocardial ischaemia characterized by typical
substernal pain which is evoked by physical exertion
and relieved by rest or sublingual nitroglycerine.

3.

Myocardial infarction:- The incidence of myocardial


infarction during the peri-operative period is related
to time period since the previous myocardial infarction. According to Tarhan et al incidence of perioperative re-infarction is 37% if the time elapsed is
less than 3 months,16% when time elapsed is 4-6
months and 5% when time elapsed is more than 6
months. This is the basis for recommendation to wait
for 6 months after MI for elective major surgery.

4.

Co-existing noncardiac diseases


i. Peripheral vascular disease ii. Cerebro vascular
disease iii. Chronic obstructive pulmonary disease in
patients with history of cigarette smoking iv. Renal
dysfunction may be associated with chronic hypertension v. Diabetes- May be the cause of silent MI

Risk factors Influencing peri-operative cardiac


morbidity are:
i.Recent myocardial infarction ii.Congestive cardiac failure iii.Peripheral vascular disease iv.Angina pectoris
v.Diabetes mellitus vi.Hypertension vii. Hypercholesterolemia viii. Dysrrhythmias ix. Age x. Renal dysfunction
xi.Obesity xii.Life style and smoking

Risk stratification
In 1977, Goldman and colleagues proposed the landmark Cardiac Risk Index2 . Although not validated prospectively, this index was used extensively for preoperative cardiac risk assessment for the next two decades.
Subsequently, other cardiac risk indices were proposed
and adopted. In 1996, a 12-member task force of the
American College of Cardiology and the American Heart
Association (ACC/AHA) published guidelines regarding
the perioperative cardiovascular evaluation of patients
undergoing noncardiac surgery3 . In March 2002, these
guidelines were updated based on new data. The overriding theme remains that preoperative intervention is rarely
necessary, simply to lower the risk of surgery, unless such

1. Professor & Head, 2. Assistant Professor Deptt. of Anaesthesiology and Resuscitation, Dayanand Medical College & Hospital, Ludhiana.
Correspondence to: Geeta Tayal 1841, Street No. 6, Maharaj Nagar,Ludhiana. 141001. Email: kaultejk@yahoo.com

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Tej K. Kaul et al. Non cardiac surgery in cardiac patients

Cardiac risk indices


S.No. Cardiac risk variables
Goldman cardiac risk index

Points Co mme n ts

5.

1.

Third heart sound or jugular


venous distension

11

2.

Recent myocardial infarction

10

Cardiac complication rate:

3.

Nonsinus rhythm or premature


atrial contraction on ECG

0-5 points = 1%

4.

More than 5 premature


ventricular contractions

5.

Age more than 70 years

6.

Emergency operations

7.

Poor general medical condition

13-25 points=14%

8.

Intrathoracic, intraperitoneal
or aortic operation

>26 points =78%

9.

Aortic stenosis

Detsky modified multifactorial index

6.
6-12 points = 7%

Class 4 angina

20

2.

Suspected critical aortic stenosis

20

3.

Myocardial infarction within


6 months

10

4.

Alveolar pulmonary edema


within 1 week

10

5.

Unstable angina within 3 months

10

6.

Class 3 angina

10

7.

Emergency operation

10

8.

Myocardial infarction more


than 6 months ago

9.

Alveolar pulmonary edema


resolved more than 1 week ago

10.

Rhythm other than sinus or


PACs on EKG

11.

More than 5 premature


ventricular contractions (PVC)
any time before surgery

12.

Poor general medical status

13.

Age more than 70 years

Dysrrhythmias.

Examination
A careful general physical examination should be
done. It should include assessment of vital signs like blood
pressure, pulse rate and rhythm, jugular venous
pulse,oedema, pallor, cyanosis, clubbing , jaundice, lymphadenopathy. In systemic examination, cardiovascular
system should be examined for heart sounds & any murmur. Further evaluation is needed as per the findings.
Respiratory system also needs to be assessed in details.

3
4

1.

7.

vi. Anaemia, polycythemia, thrombocytosis when


present will need careful management.
Current medications-Awareness about the medications that patient is taking is important during anaesthesia. All cardiac medications like beta blockers,
calcium channel blockers, nitrates should be continued until the morning of surgery.Patient may be on
oral anticoagulants or aspirin which should be stopped
5-7 days prior to surgery.
Congestive cardiac failure:-The stress of
anaesthesia,surgery and fluid replacement may result in overt failure in patients bordering on congestive heart failure.

Laboratory investigations

Cardiac complication rate:

> 15: high risk

Cardiac specific tests like ECG, echocardiography


to know ejection fraction, any valvular lesion , wall motion abnormalities, LV function and pressure gradients,
Holter monitoring, Treadmill test, thallium scintigraphy to detect myocardium at risk, radionuclide ventriculography, dobutamine stress test(DST) for evaluating inducible ischemia in patients who have poor functional capacity, coronary angiography in patients where
DST is positive should be done.

Anaesthetic management

Eagle criteria for cardiac risk assessment

Anaesthesia goals remain


5

1.

Age more than 70 years

2.

Diabetes

<1: no testing

3.

Angina

1-2 : send for


non-invasive test

4.

Q waves on ECG

5.

Ventricular arrhythmias

>3: send for


angiography

i. Stable haemodynamics ii. Prevent MI by optimizing myocardial oxygen supply and reducing oxygen demand iii. Monitor for ischaemia iv. Treat ischemia or infarction if it develops v. Normothermia vi. Avoidance of
significant anaemia
Management depends upon the type of surgery
whether emergency or elective. For emergency surgery
proceed for the surgery with medical management of
cardiac ailment. For elective surgery perioperative man281

Indian Journal of Anaesthesia, August 2007


agement depends upon various clinical risk factors and
surgery specific risk factors3.

Clinical risk factors


Obtained by history, physical examination & review of
ECG, the clinical risk factors are grouped into 3 categories1.

Major clinical predictors are unstable coronary syndrome, decompensated heart failure, significant
dysrrhythmia and severe valvular disease. They mandate intensive management even if that leads to delay or cancellation except emergency surgery.

2.

Intermediate clinical predictors are mild angina pectoris, previous MI by history or pathological Q waves,
compensated or prior heart failure, insulin dependent
diabetes mellitus,and renal insufficiency. These are
markers of enhanced risk of peri-operative cardiac
complications. It appears reasonable to wait for 4-6
weeks after MI for elective surgery.

3.

Minor clinical predictors are hypertension, LBBB,


nonspecific ST-T wave changes and history of stroke.
They have not proved to increase risk independently.

Surgery specific risk factors


1. High risk surgeries- (emergent major operations
particularly in the elderly, aortic and other major vascular surgery, anticipated prolonged surgical procedures associated with large fluid shifts or anticipated
blood loss) are often reported to have a cardiac risk
of greater than 5%.
2. Intermediate risk surgeries- (carotid endarterectomy, head and neck surgery, intraperitoneal and
intrathoracic surgery, prostate surgery) are reported
generally to have cardiac risk of less than 5%.
3. Low risk procedures:- (endoscopic procedures, superficial procedures, cataract surgeries, breast surgery)
are reported to have less than 1% risk of cardiac events.

Preoperative management
At risk patients need to be managed with pharmacologic and other perioperative interventions that can ameliorate perioperative cardiac events . Three therapeutic
options are available before elective noncardiac surgery.1.

Optimisation of medical management

2.

Revascularization by PCI, revascularization by surgery ( CABG)

However it may not be necessary to intervene preoperatively (except for beta blocker therapy or 2 agonists) to improve perioperative outcome. Beta blockers
have been shown to be useful in reducing perioperative
morbidity and mortality in high risk cardiac patients and
preferably titrated to a heart rate of 50 to 60 bpm7. 2
agonists by virtue of their sympatholytic effects can be
useful in patients where beta blockers are contraindicated.
Nitroglycerine lowers LVEDP by reducing preload . It
improves collateral coronary flow and reduce systemic
B.P. Other agents like calcium channel blockers , ACE
inhibitors, aspirin, insulin, statins prove to be beneficial
perioperatively.
Coronary intervention should be guided by patients
cardiac condition( unstable angina, left main or equivalent
CAD, three vessel disease,decreased LV function) and
by the potential consequences of delaying the noncardiac
surgery for recovery after coronary revascularization 3
.Patients who underwent PCI had better outcome after
noncardiac surgery. However the need for dual anti-platelet therapy for several months to one year can significantly impact the perioperative course. Acute postoperative stent thrombosis has been reported when anti-platelet agents were temporarily held preoperatively to reduce
chance of bleeding. Continuing the therapy can lead to
significant postoperative bleeding. Discontinuing or modifying anti-platelet therapy should involve a multidisciplinary
team of cardiologist, surgeon, anaesthesiologist 8 .

Preanaesthetic considerations
Preoperative visit to the patient is very important. A
good rapport should be made with the patient and written
consent obtained. Patient should be explained about the
risk of surgery and anaesthesia.It is important to continue
the medications till the day of surgery like beta
blockers,calcium channel blocker ,digitalis.Potassium level
should be normal as hypokalemia can cause digitalis toxicity. Anticoagulants should be stopped.

Premedication
Significance of premedication in allaying anxiety in
cardiac patients is of paramount importance. This is to
prevent increase in B.P. and HR which can disturb the
myocardial oxygen supply and demand and can induce
ischaemia. Any combination of benzodiazepine like
lorazepam and opioid like morphine should be given one
hour prior to arrival in operation theatre.

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Tej K. Kaul et al. Non cardiac surgery in cardiac patients


The following algorithm helps in easy reference for planning perioperative management of cardiac patients
undergoing noncardiac surgery.

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Indian Journal of Anaesthesia, August 2007

Intraoperative management
Monitoring
Incidence of ischaemia in the intraoperative period
is low( as compared with pre and postoperative period)
i. ECG is the most commonly used monitoring tool .
If ECG is to be used effectively as an ischaemic monitor,
the monitor should be set on diagnostic mode. Monitoring
three ECG leads ( II,V4,V5 or V3,V4,V5 ) improves recognition of ischaemia. The ST segment trending system
also helps in the detection of ischaemia ii. Blood pressure
iii. Pulse oximetry iv. Capnography v. Temperature monitoring vi. Urine output monitoring vii. Central venous pressure viii. Pulmonary artery pressure and cardiac output
can be measured with pulmonary artery catheter as required. In a haemodynamically unstable patient, the requirement of volume or inotropes can be judiciously calculated and response monitored closely ix. TEE
(transesophageal echocardiography) is a sensitive monitor for ischaemia. However TEE is not advocated for
routine use 9.

Choice of anaesthetics

EtomidateIt causes minimum haemodynamic


changes. It is excellent for induction in patients with poor
cardiac reserve.
2. NarcoticsMorphine is the preferred drug for
its relative cardiac stability and very good analgesic
effect.It produces arterial and venous dilatation ,resulting
in reduction of afterload and preload.Newer narcotic analgesic agents like fentanyl, alfentanyl and sufentanil also
provide adequate cardiac stability and pain relief.
3. Inhalational agents- Isoflurane is recommended
in patients with good myocardial contractility. Halothane
has the disadvantage of myocardial depression and potential of dysrrhythmias.
4. Nitrous oxide It provides stable haemodynamics
in cardiac patients.
5. Muscle relaxants-Vecuronium produces minimum haemodynamic alterations and is short acting , therefore suitable for use in cardiac patients. Pipecuronium,
mivacurium, doxacurium are newer non depolarizing
muscle relaxants without any significant cardiovascular
side effects.

The anaesthesiologist should select the drugs with


the objective of minimizing demand and optimum supply of
oxygen. Along with the anaesthetic agent some cardiac
drugs should be readily available to maintain
haemodynamics, to prevent & treat ischaemia, if it occurs.

6. GlycopyrrolateIt is preferred over atropine


since it produces less tachycardia & should be used only
if specifically required.

General anaesthesia

The potential and well known advantage of regional


anaesthesia over G.A should be an asset in cardiac patients if the surgery can be performed under regional block.
Patient should be nicely premedicated without any apprehension. Disadvantages of regional anaesthesia include
hypotension from uncontrolled sympathetic blockade and
need for volume loading can result in ischemia. Care
should be taken while giving local anaesthetic because
larger doses can cause myocardial toxicity and myocardial depression. Use of epinephrine with local anaesthetic
is not recommended10.

1. Intravenous anaesthetics
ThiopentoneIt reduces myocardial contractility, preload and blood pressure and there is slight increase in heart rate. It should be administered slowly
and with caution.
Propofol-It reduces arterial blood pressure and
heart rate significantly. There is dose dependent reduction in myocardial contractility.It can be used in with good
ventricular function but is not good induction agent for
patients with CAD.
Ketamine-It is not good in IHD and valvular heart
disease patients.It is however a useful agent in situations
like cardiac tamponade and cyanotic heart disease.

Regional anaesthesia

Managing intraoperative complications


1) Intraoperative ischaemia

MidazolamIt produces decrease in mean arterial pressure and increase in heart rate. It provides excellent amnesia and is widely used for patient with CAD
284

1 If patient is haemodynamically stable


1- Beta blockers ( I/V metoprolol upto 15mg)
I/V Nitroglycerine
Heparin after consultation with surgeon

Tej K. Kaul et al. Non cardiac surgery in cardiac patients


2 If patient is haemodynamically unstableSupport with inotropes
Use of intraoperative ballon pump may be necessary
Urgent consultation with cardiologist to plan for
earliest possible cardiac catheterization
2) Other complications like dysrrhythmias, pacemaker
dysfunction should be managed accordingly

Post operative management


Goals are same as intraoperative
i. Prevent ischaemia ii. Monitor for MI iii. Treatment for MI
Although most cardiac events occur within first 48
hours, delayed cardiac events (within first 30 days ) still
happen and could be the result of secondary stress. Post
operative stress of extubation, pain, sepsis, haemorrhage,
anaemia, respiratory problems can increase the demand
on the heart and should be minimized and treated.

Valvular heart diseases


Patients with valvular heart diseases coming for
surgery present many challenges to the anaesthesiologist.
Now it is no longer necessary or even advisable to delay
surgery until advanced symptoms are present. Valvular
surgery is advised in such patients before elective noncardiac surgery. The perioperative physician has to be
aware of the varying effects of haemodynamic variables
on this sub population of patients. The five variables in
dealing with the valvular heart diseases are important.
They are:- i. Preload ii. Afterload iii. Myocardial contractility iv. Heart rate v. Rhythm.
Keeping in mind these variables , the anaesthetic
technique can be chosen with a view to maintain optimal
cardiac performance. In general ,the goal in stenotic lesions is to enhance forward flow , where as in regurgitant
lesions is to decrease regurgitant flow . All the patients
with valvular heart disease undergoing non-cardiac surgery should get antibiotic prophylaxis to prevent infective
endocarditis. AHA recommends ampicillin, 2 g I.M or I.V
plus gentamicin 1.5 mg.kg-1 I.M or I.V 30 min. before
procedure and 6 hrs later ampicillin 1 gm I.M or I.V. For
patients allergic to penicillin, vancomycin 1 gm I.V is recommended. For dental and endoscopic procedures, oral
amoxicillin 2gm or cephalexin 2 gm or azithromycin 500
mg ,1 hr. before the procedure is given. Use of oral anti-

coagulants in patients with mitral stenosis who have atrial


fibrillation should be kept in mind. Tachycardia is detrimental in both aortic and mitral stenosis. In MR and AR ,
it is advisable to maintain normal to high heart rate and
mild vasodilatation to decrease the amount of regurgitant
flow. In AS consideration should be given to the possibility of CAD 11

Hypertension
Hypertension is the commonest cardiac disease all
over the world. These patients are documented to have
associated CAD, left ventricular dysfunction, renal failure
which increase the perioperative risk. Hence it is advisable
to control BP preoperatively. But this does not need surgery to be deferred for weeks, to achieve ideal blood pressure control, in patients with mild to moderate hypertension. It is also important to evaluate for target organ damage. It is advisable to continue antihypertensives till the day
of surgery. For patients with marked elevations of BP intra
or post operatively should be managed by either nitroglycerine or sodiumnitroprusside by I.V. infusion. Intraarterial
B.P. monitoring is recommended for such patients. Any
factors of sympathetic stimulus should be avoided.

Dysrrhythmias
Dysrrhythmias may be a marker of severity of underlying CAD or left ventricular dysfunction. Asymptomatic ventricular ectopics with stable haemodynamic parameters do not need any treatment preoperatively. Similarly prophylactic treatment is not required in supraventricular tachycardia . In atrial fibrillation rate needs to be
controlled . Perioperatively if they occur can be treated
by calcium channel blockers ,beta blockers,adenosine.
Patients with conduction delay ,LBBB do not require pacing unless there is history of syncope.But in complete heart block, patients need to be paced.In patients on
permanent pace makers ,electro cautery should be used
with caution and for minimum period of time.The cautery plate should be as far as possible from the heart .Use
of bipolar cautery decreases the risk of pacemaker dysfunction. Use of magnet will turn pace maker into asynchronous mode , preventing unwanted inhibition.
The material submitted remains only an overview
of the guidelines, which will continue changing from time
to time, depending upon the evidence procured over a
period of time. Also the techniques need to be tailored
varying from patient to patient, surgical needs and the
facilities available.

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Indian Journal of Anaesthesia, August 2007

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Goldman L,Caldera D,Nussbaum S, et al. Multifactorial index of


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London MJ, Zaugg M, Schaub MC, et al. Perioperative betaadrenergic receptor blockade: physiologic foundations and clinical controversies. Anesthesiology 2004; 100:170.

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Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline


update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary. A report of the American College of Cardiology / American Heart Association Task Force on
Practice Guidelines (Committee to update the 1996 guidelines
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Detsky AS, Abrams HB, Forbath N , et al. Cardiac assessment


for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med 1986; 146:2131.

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Eagle K, Brundage B, Chaitman B, et al. Guidelines for


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10. Breen P, Park K W. General anesthesia versus regional anesthesia. Int Anesthesiol Clin 2002; 40:61.
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Circulation 1998;98:1949-84.

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