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ischemicPreconditioning - PresentedApr2003 Ischemic...

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Ischemic  Preconditioning (IPC) Darko J. Vodopich MD Resident @ MHMC-CWRU Department of Anesthesiology Charles E. Smith MD, FRCPC  Director of Cardiothoracic Anesthesia @ MHMC-CWRU  Department of Anesthesiology Presented Apr 2003
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Objectives  Introduction to the topic of IP  Risk factors for CAD  Cardiac anatomy and ischemia  Ischemic preconditioning (IPC)  and  anesthetic agents  Summary
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Epidemiology  CAD is the leading cause of death  Direct cost of cardiovascular care > 260 billion  ~ 1,000,000 deaths form CAD per year  Every 29 seconds one American dies of AMI  Cost of CABG > 12 billion  (2% of all heath care costs)  In US  (1996)  ~ 300,000 CABG; 400,000 PTCA  Waiting time for CABG  (UK, Sweden, Canada)  > 9 mo.
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What is cardiac ischemia?   Cardiac ischemia  is a situation in  which the  blood   flow  within a  coronary  artery is limited to the point  where the  oxygen demands  of the heart  muscle  cannot be met ( hypoxia ).  * Impaired oxygen supply/demand ratio.
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Coronary artery distribution   LV -   Anterior - LAD Anterolateral - OM branch CxA   Inferior - PDA branch of RCA, CxA Apex - Distal LAD Posterior / Posterolateral - CxA Septum - septal branches of LAD  RV  - RCA, and branches of LAD and CxA  Sinus node  - proximal RCA (55%), CxA (45%)  A-V node  - distal RCA (90%), CxA (10%)
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 Chest pain if patient is awake  ECG changes  Hypotension  Tachycardia  Elevated pulmonary artery occlusion pressure  (PAOP)  Large v-waves on PAOP tracing  Fall in cardiac output/index  Detection with TTE/TEE Methods to Detect Ischemia
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Intraoperative ECG monitoring  Computerized ST segment  monitoring  ST depression > 1 mm 60 msec  after J-point  Slope of the depression   horizontal    downsloping J-point Isoelectric point
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LAD CxA RCA V 1 -V 4 I, aVL, V 5 -V 6 II, aVF Anatomic location of ischemia on  ECG
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Sensitivity of ECG lead  combinations II / V 5  - 80 % II / V 4  - 82 % V 4  / V 5  - 90 % Two lead system London, Anesthesiology, 1998; Vol 69, 232
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Sensitivity of ECG lead  combinations V 3 /V 4 /V 5  - 94 % II/V 4 /V 5  - 96 % Three lead system London, Anesthesiology, 1998; Vol 69, 232
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 Five standard ASA monitors:  POX  BP  EtCO 2  ECG  Temperature  Intraarterial catheter  Pulmonary artery catheter (PAC)  CO/CI (not truly continuous)  CVP  PCWP  LVSWI  SVR,PVR  TTE/TEE  (currently not routinely available @ MHMC)  LidCO/Pulse CO*  Continuous SV, MAP, SVR, CO, SPV** * integration of arterial pressure wave form ** systolic peak velocity Intraoperative Monitoring
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Treatment of ischemia Miller 5 th edition; page 1763
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