CHAPTER 33 Ischemic Heart Disease
6 How is angina graded?
The Canadian Cardiovascular Society introduced a grading system for angina:
Class I | Angina with strenuous or rapid prolonged exertion at work or recreation |
Class II | Angina with walking or climbing stairs rapidly, walking uphill, or walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace |
Class III | Angina with walking one to two blocks on the level and climbing one flight of stairs at a normal pace |
Class IV | Angina may be present at very low level of physical activity or at rest |
8 What clinical factors increase the risk of a perioperative myocardial infarction following noncardiac surgery?
There are active cardiac conditions, clinical risk factors, and minor clinical predictors based on the algorithm for risk stratification and appropriate use of diagnostic testing of cardiac patients undergoing noncardiac surgery by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Perioperative Evaluation (2007). The guidelines integrate clinical risk factors, exercise capacity, and the surgical procedure in the decision-making process. They are discussed in more detail in Chapter 17.
10 How does the type of surgery influence the risk stratification for perioperative ischemia?

12 When would you consider noninvasive stress testing before noncardiac surgery?


13 What tests performed by medical consultants can help further evaluate patients with known or suspected ischemic heart disease?






KEY POINTS: Ischemic Heart Disease
14 What are the main indications for coronary revascularization before noncardiac surgery?

15 A patient after percutaneous coronary intervention is scheduled for surgery. What is your concern?
16 Why do patients with drug-eluting stents need significantly longer time than those with bare metal stents?
21 When is a resting 12-lead ECG recommended?

22 How long should a patient with a recent myocardial infarction wait before undergoing elective noncardiac surgery?
23 Outline the hemodynamic goals of induction and maintenance of general anesthesia in patients with IHD
25 Would you use transesophageal echocardiography routinely in patients with high cardiac risk undergoing noncardiac surgery?
26 Is a pulmonary artery catheter reasonable to use routinely for optimization of high-risk patients? What is its potential benefit?
The use of pulmonary artery catheters in patients with IHD has not been shown to improve outcome; thus it should be restricted to a very small number of well-selected patients whose presentation is unstable and who have multiple comorbid conditions. When used, the pulmonary artery occlusion (wedge) pressure gives an estimation of the left ventricular end-diastolic pressure, which is a useful guide for optimizing intravascular fluid therapy. Sudden increases in the wedge pressure may indicate acute left ventricular dysfunction caused by ischemia. See Chapter 26.
1. Fleisher L.A., Beckman J.A., Brown K.A., et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation. 2007;116:1971-1996.
2. Newsome L.T., Kutcher M.A., Royster R.L. Coronary artery stents. Part 1. Evolution of percutaneous coronary intervention. Anesth Analg. 2008;107:552-569.
3. Newsome L.T., Weller R.S., Gerancher J.C., et al. Coronary artery stents. Part II. Perioperative considerations and management. Anesth Analg. 2008;107:570-590.