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Ischaemic heart disease, hypertension and heart failure in anaesthesia
In a patient with ischaemic heart disease the aim is to keep the balance between myocardial oxygen supply and demand: a slow heart rate, a good diastolic pressure, no pain, cold or severe anaemia; and in a patient with hypertension or heart failure — to keep blood pressure stable and not depress the heart.
Why it matters in the exam
The exam asks about detecting ischaemia during surgery (lead V5 and lead II), treating ischaemia during surgery, continuing beta blockers and statins, the POISE trial and the danger of starting a high-dose beta blocker on the day of surgery, myocardial injury after surgery (MINS) and troponin measurement, the blood pressure values that postpone surgery, and the effect of a mean pressure below 65 on the kidneys and heart.
Ischaemia during surgery usually appears without pain, as an ST-segment change, a fall in pressure, an arrhythmia or a wall-motion change on transoesophageal echo. Lead V5 detects most events, and adding lead II improves detection. Treatment: check oxygenation and haemoglobin, slow tachycardia with a beta blocker, correct hypotension with a vasoconstrictor, give nitroglycerin only if blood pressure allows, deepen anaesthesia and relieve pain. If there is persistent ST elevation — consult a cardiologist about catheterisation, weighing the bleeding risk from surgery. The POISE trial from 2008 showed that starting a high-dose beta blocker close to surgery reduced heart attacks but raised stroke and death; so a beta blocker is continued in those already taking one, and not started at high dose on the day of surgery.
Under the ESC guidelines from 2022, in high-risk patients troponin is measured before major surgery and 24 and 48 hours after it, because most myocardial injuries after surgery are silent and linked to death. After elective stent placement, non-urgent surgery is usually postponed for at least 6 months, and after an acute coronary syndrome 12 months. In hypertension, elective surgery is usually postponed if the pressure is 180/110 or higher; lower values are not a reason to postpone. During surgery a mean pressure above about 65 is kept, because prolonged hypotension is linked to kidney and heart injury. In heart failure with reduced function, fluids are balanced carefully, strong myocardial depression is avoided, and arterial monitoring and high-dependency admission are planned.
Key points
- The aim: high supply, low demand.
- Continue beta blocker and statin; do not start a high-dose beta blocker on the day of surgery.
- V5 and II detect most ischaemia.
- Postpone elective surgery if the pressure is 180/110 or higher.
- A mean pressure below 65 is linked to kidney and heart injury.
Summary table
| Condition | Management | Exam point |
|---|---|---|
| Ischaemia during surgery | Oxygen, haemoglobin, slow the heart rate, correct pressure, nitroglycerin if pressure allows | Usually painless; V5 detects most events |
| Beta blocker | Continue if the patient takes it; do not start at high dose on the day of surgery | POISE 2008: more stroke and death |
| Troponin after surgery | High risk: before, and 24 and 48 hours after | MINS is usually silent |
| Stent | Postpone elective surgery 6 months after elective stenting, 12 after an acute event | Do not stop aspirin in most patients |
| Hypertension | Postpone elective surgery if 180/110 or higher | In surgery keep the mean pressure above 65 |
| Heart failure | Fluids with care, avoid depression, arterial monitoring | Look for signs of decompensation before surgery |
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Sources
- ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery, 2022 — Ischaemic heart disease, hypertension, heart failure
- Miller's Anesthesia, 9th edition (2020) — Anesthesia for patients with cardiac disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.