coranary artery disease &Cardiac surgery demand supply Myocardial ischemia: -stable angina pectolaris(when no change in precipitating factors, frequency, and duration has occurred for at least 60 days. - unstable angina pectoralis(Chest pain produced with less than normal activity and lasting for increasingly longer periods is considered characteristic of unstable angina pectoris and may signal an impending myocardial infarction. - myocardial ischemia without angina - variant or Prinzmetal's angina Angina pectoris caused by spasm of the coronary arteries differs from classic angina pectoris in that it may occur at rest and then be absent during vigorous exertion FACTORS THAT INCREASE THE RISK FOR PERIOPERATIVE MYOCARDIAL INFARCTION 1) the site of the previous myocardial infarction, 2) a history of prior coronary artery bypass graft (CAB G) surgery, 3) intrathoracic or intra-abdominal operations lasting longer than 3 hours, 4) the site of the operative procedure if the duration of the surgery is less than 3 hours, and 5) techniques used to produce anesthesia. Noninvasive cardiac diagnostic studies 1- EKG 2-Chest X ray 3-Exercise tolerance test(ETT) 4-Echocardiography transthoracic-trans esophagial 5-Stress echocardiography 5-Radionuclid imaging 6-Cardiac catheterization EF= EDV-ESV EDV = SV EDV Medical treatment of ischemia 1- Antiplatelet drugs: aspirin clpidogrol(plavix) Platelate glycoprotein IIa/IIIb recceptor antagonist(abciximab) 2- Antithrombin drugs; heparin-low molecuiar weight heparin(LMWH) warfarin Conti.. 3- beta blocker 4- calcium channel blocker 5- nitrate 6- revascularization Percutaneous coronary intervention(PCI)- stent coronary artery by pass(CABG) 7- ACE inhibitor 8- Angiotensin II receptor antagonist 9- Digital achidna Cardiopulmonary by pass (CPB) PH managemant Lab (37c) pHa 7.25 Paco2 56 pHa 7.4 Paco2 40 pH-ststalpha-stat Lab (37c) pHa 7.4 Paco2 40 pHa 7.56 Paco2 26 (28c) Valvular heart disease Prosthetic heart valves Mechanical: composed primarily of metal or carbon alloys -caged ball, single tilting disk, or bileaflet tilting disk valves Bioprosthetic(heterografts): porcine or bovine homographt-autographt Caged Ball Design (Mechanical Heart Valve) ASpressure overloadconcenteric hypertrophy ARvolume overloadeccenteric hypertrophy A=atrial contraction C=ventricular contraction V=systolic filling the atrium