• Aim
  • HR 55 + SBP 110
  • SBP < 130
  • MAP 70
  • HR 70
• SAAB = Statin + Aspirin + ACEi + BB

• IHD = Ischaemic heart Disease
• CAD = Coronary Artery Disease
  • a subset of IHD
  • atheroma-related obstructive disease
  • there is also NON-OBSTRUCTIVE Ischaemic heart disease, eg:
    • coronary vasospasm
    • microvascular disease

CCS angina grading scale (I-IV)

• Class I = no symptoms with ordinary activity

• Class II = symptoms with ordinary activity

• Class III = marked symptoms with minimal activity

• Class IV = symptoms at rest

• SYNTAX score

  • complexity of CAD
  • used for considering CABG vs PCI

• At risk

• ⬆risk MACE
• co-morbidities
  • HTN, stroke, renal dysfunction, PVD, DM, smoking

• Patient (6)
  • DM, HChol, HTN, smoking, FH, obesity
• High risk
  • Unstable / severe angina
  • CABG / PCI < 6 weeks
  • AMI < 1 month

• myocardial ischaemia = myocardial O2 demand exceeds supply
• myocardial supply
  • Blood O2 content
  • coronary BQ (Q = P / R)
    • pressure
      • aortic root pressure
      • LVEDP
      • time = diastolic time
    • resistance
      • blood viscosity
      • diameter = neurohormonal regulation
• myocardial demand
  • HR
    • bradyC = ⬇O2 demand, ⬆diastolic time for CBQ but ⬇CPP and ⬇CBF
    • tachyC = ⬇diastolic time, may worsen/induce ischaemia
  • SBP
    • high = ⬆myocardial wall tension = ⬆O2 demand
    • low = ⬇O2 demand but ⬇BQ, ⬇supply

• ischaemia = chest pain
• LVF = SOB, orthopnoea, PND
• RVF = oedema

• Pre-op
  • balance risk/benefits of surgery against time for investigations
  • medication management (see MACE)
  • consider CR
• Intra-op
  • optimise myocardial O2 supply and demand
  • 1:PL
    • Maintain normovolaemia
    • keep the heart small to ⬇wall tension / LVEDP and ⬇coronary perfusion pressure gradient
  • 2:HR
    • slow
    • avoid tachycardia
  • 3:Rhythm
  • 4:INO
    • Avoid myocardial depression
  • 5:AL
    • Avoid hypo/hypertension
    • Adequate analgesia
  • High risk periods
    • intubation / extubation
  • Maintain Hb > 90 g/L
    • Hb > 100 g/L
• Post-op

• minimum duration APT
  • balloon angioplasty = 2 weeks
  • BMS = 4 weeks
  • DES = 1 year (may be less, check current guidelines)
• recent MI
  • defer 60 days = 2 months = if no PCI before NCS
  • MI within 6 months = independent RF for periop stroke, 8x periop mortality

• ECG
  • new ST/T changes
  • new LBBB
  • arrhythmias, conduction abnormalities
  • new pathological Q waves
• Vitals
  • unexplained ⬆HR, ⬇HR, ⬇BP
• Echo
  • regional wall abnormalities
  • new / worse MR
• Management
  • assess need for airway Mx / CPR
  • verify ischaemia
    • 12-lead ECG
    • expanded monitor view
    • TEE/TOE = RWMA
  • ⬆myocardial O2 supply
    • ⬆FiO2 = 100% O2
    • Treat anaemia
    • Optimise coronary BQ
      • ⬆CPP = optimise BP
      • adequate diastole = treat tachycardia
      • consider IABP if HDI
    • Revascularisation
      • discuss with surgical and cardiology teams
      • interventional = cath lab
      • medical = ATT = ACT/APT
  • ⬇myocardial O2 demand
    • HR / INO / AL / ENS
      • avoid tachycardia
      • analgesia, BB, nitrates
  • postop CCU/HDU/ICU

Final FRCA In A Box

https://heart.bmj.com/content/104/4/284

https://www.anesthesiaconsiderations.com/coronary-artery-disease