46-year-old male with occluded left MCA
- Occluded MCA
- Attempted stenting previously. Stent thrombosed intraoperatively, required thrombolysis
- Progressive right sided weakness – recent onset
- ? IHD
- STEMI – angiogram showed only moderate diffuse disease
- 2nd STEMI 2017 – angiogram showed spasm, resolved during PCI with intra-arterial vasodilator therapy
- Regular cardiology review. Multiple therapies trialed for coronary artery spasm and hypertension
- Patient cannot tolerate verapamil PO.
- Grade 3 HTN
- 200/110 in clinic.
- Since age 14yo.
- Symptomatic if SBP < 165. Dizzy and nauseated
- Headache when SBP>240
- Equal in both arms
- Extensively investigated including renin-angiotension levels etc, no cause elucidated.
- Non-smoker, no DM
- New ECG changes in clinic – TWI in I and V5-6 (? LVH although only mild LVH on recent TTE)
- HTN unoptimised
- Monthly chest pain – Responsive to GTN.
- Chest pain much improved since commencement of Diltiazem
- Symptomatic at values higher or lower than a specific range
- Nil further perioperative management is indicated.
- Neurosurgery team aware
- BP targets post-op? Risk of hyperemic brain injury v. “hypotensive” infarct
- Frequent CP
- Given unremarkable angiogram findings, in keeping with coronary vasospasm
- Level of postop care
- ICU 2 vs 3
- Postoperative BP will require close monitoring and control
- Invasive BP measurement would be optimal
- Ward setting unlikely to be suitable in first 24/48 hours
- Discuss with surgeons – “yes will need strict BP control and monitoring.”
- ICU level 2
- Discuss new ECG changes with treating cardiologist
- Notification of procedural anaesthetist
- Continue all antihypertensives preop