How does ischemic heart disease (IHD) affect perioperative cardiac management?

Updated: Feb 04, 2019
  • Author: Davinder Jassal, MD; Chief Editor: William A Schwer, MD  more...
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Answer

Ischemic heart disease (IHD) is a major determinant of perioperative morbidity and mortality. During the 1970s, several studies reported a 30% risk of reinfarction or cardiac death for patients undergoing surgery within 3 months of an MI, 15% when surgery was performed 3-6 months after an infarction, and 5% when the operation was performed 6 months later. However, this traditional definition has been replaced by the consensus of the American College of Cardiology (ACC) Cardiovascular Database Committee. In particular, an acute MI is now defined as occurring within 7 days, a recent MI is defined as occurring within 7 days to 1 month, and a history of prior MI refers to an event occurring more than 1 month previously.

True lifesaving procedures should be performed regardless of cardiac risk, but consideration should be given to performing elective surgery 4-6 weeks following an MI. In patients requiring semi-urgent surgery, the patient's risk should be evaluated with prognostic studies (see Preoperative Risk Assessment). In a 1990 report, Shah et al revealed that 25% of patients with unstable angina had an MI after noncardiac procedures. [5] Medical therapy and/or revascularization are necessary to ameliorate this risk factor.

No evidence-based trials compare perioperative cardiac outcome after noncardiac surgery for individuals treated with preoperative percutaneous coronary intervention (PCI) versus medical therapy. Indications for PCI in the perioperative setting should adhere to the ACC/American Heart Association (AHA) guidelines established for PCI in general. In the setting of PCI without stenting, wait 1 week prior to surgery. In the setting of PCI with a coronary stent, wait 4-6 weeks prior to noncardiac surgery.


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