Conclusions
Techniques which detect the mechanical and electrical manifestations of ischaemia are defining the incidence and temporal pattern of perioperative ischaemia. Preoperative ischaemia is more common than previously thought, tends to be silent, and is unrelated to systemic haemodynamic changes. Intraoperative ischaemia is often unrelated to haemodynamics, and may reflect the preoperative ischaemic pattern more than the stress of anaesthesia and surgery. Postoperative ischaemia in noncardiac surgery is also silent and may be prolonged and severe. Perioperative ischaemia is associated with adverse postoperative cardiac events both after CABG and noncardiac surgery. The possibility that perioperative ischaemia may cause postoperative infarction has not been ruled out. However, it is more likely that ischaemia and infarction are two unrelated manifestations of severe underlying coronary artery disease. Further investigations are needed to resolve this intriguing controversy.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardio-graphic and symptomatic expressions of ischemia. Am J Cardiol 1987; 57: 23C-30C.
Bellows, WH, Bode RH, Levy JH, Foex P, Lowenstein E. Noninvasive detection of perinduction ischemic ventricular dysfunction by cardiokymography in humans: preliminary evidence. Anesthesiology 1984; 60: 155–8.
Giles RW, Berger HJ, Barash PG et al. Continuous monitoring of left ventricular performance with the computerized nuclear probe during laryngoscopy and intubation before coronary artery bypass surgery. Am J Cardiol 1982; 50: 735–40.
Smith JS, Cahalan MK, Benefiel DJ et al. Intraoperative detection of myocardial ischemia in high-risk patients: electrocardiography versus two-dimensional echocardiography. Circulation 1985; 72: 1015–21.
London MJ, Tubau JF, Wong BS, Layug E, Mangano DT. The “natural history” of segmental wall motion abnormalities detected by intraoperative transoesophageal echocardiography: a clinically blinded prospective approach. Anesthesiology 1988; 69: A7.
Gewertz BL, Kremser PC, Zarins CK et al. Transoesophageal echocardiographic monitoring of myocardial ischemia during vascular surgery. J Vase Surg 1987; 5: 607–13.
Ellis JE, Roizen MF, Aronson S et al. Comparison of two automated ST-segment analysis systems, EKG (including T wave inversion analysis), and transesophageal echocardiography for the diagnosis of intraoperative myocardial ischemia. Anesthesiology 1988; 69: A5.
Sell TL, Croughwell N, Camporesi E, Jones RH, Reves JG. Assessment of wall motion by radionuclide angiocardiography during endotracheal intubation. Anesthesiology 1987; 67: A27.
Kleinman B, Henkin RE, Glisson SN et al. Qualitative evaluation of coronary flow during anesthetic induction using thallium-201 perfusion scans. Anesthesiology 1986; 64: 157–64.
Deanfield JE, Ribiero P, Oakley K, Krikler S, Selwyn AP. Analysis of ST-segment changes in normal subjects: implications for ambulatory monitoring in angina pectoris. Am J Cardiol 1984; 54: 1321–5.
Knight AA, Hollenberg M, London MJ et al. Perioperative myocardial ischemia: importance of the preoperative ischemic pattern. Anesthesiology 1988: 68: 681–8.
Levin RI, Cohen D, Frisbie W et al. Potential for real-time processing of the continuously monitored electrocardiogram in the detection, quantitation, and intervention of silent myocardial ischemia. Cardiology Clin 1986; 4: 735–45.
Epstein SE, Quyyumi AA, Bonow RO. Myocardial ischemia - silent or symptomatic. N Engl J Med 1988; 318: 1038–43.
Deanfield JE, Selwyn AP, Chierchia S et al. Myocardial ischaemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes. Lancet 1983; 2: 753–8.
Rocco MB, Barry J, Campbell S et al. Circadian variation of transient myocardial ischemia in patients with coronary-artery disease. Circulation 1987; 75: 395–400.
Gottlieb SO, Weisfeldt MI, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med 1986; 314: 1214–9.
Gottlieb SO, Gottlieb SH, Achuff SC. Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients. JAMA 1988; 259: 1030–5.
Chung F, Houston PL, Cheng DCH et al. Calcium channel blockade does not offer adequate protection from perioperative myocardial ischemia. Anesthesiology 1988; 69: 343–7.
Lieberman RW, Orkin FK, Jobes DR, Schwartz AJ. Hemodynamic predictors of myocardial ischemia during halothane anesthesia for coronary-artery revascularization. Anesthesiology 1983; 59: 36–41.
Moffit EA, Sethna DH, Bussell JA, Raymond M, Matloff JM, Gray RJ. Myocardial metabolism and hemodynamic responses to halothane or morphine anesthesia for coronary artery surgery. Anesth Analg 1982; 61: 979–85.
Slogoff S, Keats AS. Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anesthesiology 1985; 62: 107–14.
Slogoff S, Keats AS. Further observations on perioperative myocardial ischemia. Anesthesiology 1986; 65: 539–42.
Slogoff S, Keats AS. Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia? Anesthesiology 1988; 68: 676–80.
Wilkinson PL, Hamilton WK, Mayers JR et al. Halothane and morphine-nitrous oxide anesthesia in patients undergoing coronary artery bypass operation: patterns of intraoperative ischemia. J Thorac Cardiovasc Surg 1981; 82: 372–82.
Cheng DCH, Chung F, Burns RJ, Houston P, David T. Perioperative myocardial ischemia: predictor of infarction by technetium pyrophosphate-SPECT. Anesthesiology 1987; 67: A594.
Goehner P, Hollenberg M, Leung J, Browner W, Cason B, Mangano DT. Hemodynamic control suppresses myocardial ischemia during isoflurane or sufentanil anesthesia for CABG. Anesthesiology 1988; 69: A32.
Mitchell MM, Prakash O, Rulf ENR, Van Daele M, Cahalan MK. Does nitrous oxide induce myocardial ischemia in patients with poor ventricular function? Anesthesiology 1988; 69: A81.
Smith H, Nathan HJ. Failure to predict myocardial ischaemia in patients with coronary artery disease. Can J Anaesth 1988; 35: S80-l.
Wilton NCT, Luckoff C, Sachdev V, Kirsh M, Shea M. Silent pre-operative myocardial ischemia in surgical patients with ischemic heart disease. Anesthesiology 1987; 67: A591.
Wilton NCT, Marcus F, Michelson L, Kirsh M, Shea M. Silent myocardial ischemia in CABC patients: comparison of ischemia during sleep, following premedication, and peri-operativcly. Anesthesiology 1988; 69: A52.
Leung J, O’Kelly B, Tubau J, Browner W, Mangano DT. Regional wall motion changes during CABG: importance of the post-bypass period. Abstracts of the Annual Meeting of the Society of Cardiovascular Anesthesiologists 1988; p. 100.
Coriat P, Harari A, Daloz M, Viars P. Clinical predictors of intraoperative myocardial ischemia in patients with coronary artery disease undergoing noncardiac surgery. Acta Anaesth Scand 1982; 26: 287–90.
Coriat P, Fusciardi J, Daloz M, Harari A, Ducardonet A, Viars P. Prevention of pre-operative myocardial ischemia with continuous nitroglycerin infusion. Ann Fr Anesth Reanim 1982; 1:47–51.
Coriat P, Daloz M, Bousseau D, Fusciardi J, Echter E, Viars P. Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous nitroglycerin. Anesthesiology 1984; 61: 193–6.
Godet G, Coriat P, Baron JF et al. Prevention of intraoperative myocardial ischemia during noncardiac surgery with intravenous diltiazem: a randomized trialversus placebo. Anesthesiology 1987; 66: 241–5.
London MJ, Hollenberg M, Wong MG et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69: 232–41.
Roy WL, Edelist G, Gilbert B. Myocardial ischemia during non-cardiac surgical procedures in patients with coronary-artery disease. Anesthesiology 1979; 51:393–7.
Christopherson R, Beanie C, Manolio TA et al. Incidence of perioperative myocardial ischemia in patients having lower extremity vascular grafting. Abstracts of the Annual Meeting of the Society of Cardiovascular Anesthesiologists 1988; p. 115.
Clements F, McCann R. Perioperative silent ischemia; prevalence and significance in patients undergoing peripheral vascular surgery. Abstracts of the Annual Meeting of the Society of Cardiovascular Anesthesiologists 1988; p. 101.
Ellis JE, Roizen MF, Aronson S, Feinstein SB, Briller JE. Frequence with which ST segment trends predict intraoperative myocardial ischemia. Anesthesiology 1987; 67; A2.
Fegert G, Hollenberg M, Browner W et al. Perioperative myocardial ischemia in the noncardiac surgical patient. Anesthesiology 1988; 69: A49.
McIntyre RW, Campbell DQ, Baldwin B, Smith LR, Levin RI. Myocardial ischemia in patients undergoing non-cardiac surgery. Society of Cardiovascular Anesthesiologists 1988; p. 117.
Wong MG, Wellington YC, London MJ, Layug E, Li J, Mangano DT. Prolonged postoperative myocardial ischemia in high-risk patients undergoing non-cardiac surgery. Anesthesiology 1988; 69: A56.
Thomson IR, Putnins CL. Adverse effects of pancuronium during high-dose fentanyl anesthesia for coronary artery bypass grafting. Anesthesiology 1985; 62: 708–13.
Clements FM, Kok S, de Kok E, McCann R. Perioperative ischemia: Should we be less tolerant of tachycardia? Anesthesiology 1988; 69: A50.
Yousif H, Davies G, Westaby S, Prendiville OF, Sapsford RN, Oakley CM. Preoperative myocardial ischaemia: its relation to perioperative infarction. Br Heart J 1987; 58: 9–14.
Thomson IR, Mutch WAC, Culligan JD. Failure of intravenous nitroglycerin to prevent myocardial ischemia during fentanyl-pancuronium anesthesia. Anesthesiology 1984; 61: 385–93.
Gallagher JD, Moore RA, Jose AB, Botros SB, Clark DL. Prophylactic nitroglycerin infusions during coronary artery bypass surgery. Anesthesiology 1986; 64: 785–9.
Lowenstein E. Perianesthetic ischemic episodes cause myocardial infarction in humans — a hypothesis confirmed. Anesthesiology 1985; 62: 103–6.
Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfuntion. Circulation 1982; 66: 1146–9.
Geft I, Fishbein MC, Ninomiya K et al. Intermittent brief periods of ischemia have a cumulative effect and may cause myocardial necrosis. Circulation 1982; 66: 1150–3.
Lowenstein E, McPeek B. Capitalizing on research findings that appear to conflict. Anesthesiology 1988; 68: 668–70.
Dodds TM, Delphin E, Stone JG, Gal SG, Coromilas J. Detection of perioperative myocardial ischemia using Holter monitoring with real-time ST-segment analysis. Anesth Analg 1988; 67: 890–3.
Clements FM, McCann RL, Levin RI. Continuous ST segment analysis for the detection of perioperative myocardial ischemia. Crit Care Med 1988; 16: 710–1.
Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high risk surgical patients. Anesthesiology 1987; 66: 729–36.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Thomson, I.R. Perioperative myocardial ischaemia. Can J Anaesth 36 (Suppl 1), S35–S40 (1989). https://doi.org/10.1007/BF03005325
Issue Date:
DOI: https://doi.org/10.1007/BF03005325