Anesthetic strategy: ALR vs. AG, halogenated anesthetic vs. intravenous, analgesia

The intraoperative period is a high-risk period for coronary artery disease patient. Anesthetic management is based on both a strategy of prevention of myocardial ischemia, and of early detection and treatment of cardiac events. Optimization of hemodynamic parameters to maintain the energetic balance of the myocardium is a key point in coronary artery disease patient during the intraoperative period. The effect of anesthetic agents and of neuraxial anesthesia on the hemodynamic parameters and cardiovascular regulatory systems must be taken into account for anesthesia management. Maintenance of normothermia is recommended in patients undergoing non-cardiac surgery. The reduction of cardiac risk by neuraxial anesthesia, combined or not to general anesthesia, has not be demonstrated despite a large body of literature. Neuraxial anesthesia is efficient for postoperative pain relief, and to reduce respiratory complications in high-risk patient. Management of antiplatelet treatment, frequently used in coronary artery patients, should be considered, according to specific guidelines. Anesthetic preconditioning using a volatile anesthetic agent, although demonstrated in experimental models and highly probable in cardiac surgery, was not shown to be effective in non-cardiac surgery. The use of a volatile anesthetic agent for maintenance of anesthesia should be determined by factors other than the prevention of myocardial ischemia or myocardial infarction. The efficacy of remote ischemic preconditioning to reduce perioperative cardiac complication has not been demonstrated in non-cardiac surgery. Prevention of myocardial ischemia or infarction using prophylactic nitrates or alpha-2agonists is not recommended.