Anaesthetic management of a patient with acute appendicitis and concurrent acute coronary syndrome: A perioperative challenge

Nagesh R*, Mohan N, Nadir Abbas Malvia, Ashok M, Hemanth Kamath, Rajesh K C, Madhushree, Karthik, Monika, Vijay Sai

Department of Anaesthesiology and Critical Care, Kauvery Hospital, Electronic City, Bengaluru, India

Abstract

Background: Coexistence of acute coronary syndrome (ACS) and acute surgical abdomen poses a significant anaesthetic dilemma. Optimizing cardiac status while preventing surgical delay requires careful multidisciplinary coordination. We report a case of successful anaesthetic management of acute appendicitis in a patient presenting with concurrent ACS.

Case Presentation: A 54-year-old male with hypertension, diabetes, and a history of coronary angioplasty presented with acute appendicitis and evolving ACS. Invasive monitoring, etomidate-based induction, and controlled anaesthesia with sevoflurane were employed to maintain haemodynamic stability. The patient was electively ventilated postoperatively and recovered without cardiac complications.

Conclusion: Perioperative management of acute surgical conditions with active cardiac ischaemia requires individualized strategy guided by current perioperative cardiovascular guidelines, vigilant monitoring, and multidisciplinary teamwork.

Keywords: Acute coronary syndrome; Anaesthesia; Emergency surgery; Perioperative risk; Myocardial ischaemia.

Introduction

Emergency surgery in the presence of acute coronary syndrome (ACS) presents a complex challenge. Surgical delay can increase morbidity from sepsis or peritonitis, while anaesthesia and surgery may exacerbate myocardial ischaemia. Balancing the risks of cardiac decompensation against the need for urgent surgical intervention demands a multidisciplinary and evidence-based approach. Recent updates from the 2024 American Heart Association/American College of Cardiology (AHA/ACC) perioperative guidelines and the 2022 European Society of Cardiology (ESC) have redefined management strategies for high-risk non-cardiac surgeries [1,2].

Case Presentation

A 54-year-old male with chronic smoking, diabetes, and hypertension presented with right iliac fossa pain and chest discomfort radiating to the right shoulder. He had undergone coronary angioplasty four years prior and had discontinued cardiac medications one year ago. Examination revealed BP 110/65 mmHg, HR 80/min, SpO₂ 92%, and tenderness in the right iliac fossa. ECG demonstrated ST elevation in V2–V4 with T-wave inversion in V5–V6; troponin I was elevated. Echocardiography revealed regional wall motion abnormalities with preserved left ventricular function. Ultrasound confirmed acute appendicitis.

After multidisciplinary discussion involving cardiology and surgery, the patient was optimized with anticoagulation and nitrates. Informed consent was obtained, highlighting the cardiac risk. Under full ASA monitoring with arterial and central lines, anaesthesia was induced using etomidate 12 mg, fentanyl 100 µg, and rocuronium 50 mg. Anaesthesia was maintained with sevoflurane (0.8–1 MAC) in air–oxygen mixture. Haemodynamic parameters remained stable (MAP 70–80 mmHg). A transient ST elevation during emergence warranted elective postoperative ventilation in the ICU for 6 hours. The patient recovered uneventfully and was discharged on postoperative day 4.

Discussion

Patients presenting with concurrent ACS and surgical emergencies represent one of the highest-risk perioperative populations. The pathophysiology involves an imbalance between myocardial oxygen supply and demand due to increased sympathetic tone, tachycardia, hypotension, and inflammatory cytokine surge during surgical stress [3]. Emergency surgery within 30 days of myocardial infarction carries a 30-day mortality up to 32%, which decreases significantly after 90 days [4]. However, when infection or perforation risk mandates immediate surgery, individualized optimization guided by current guidelines becomes critical.

The 2024 AHA/ACC guideline recommends a stepwise assessment incorporating the Revised Cardiac Risk Index (RCRI), functional capacity using the Duke Activity Status Index (DASI), and selective troponin testing pre- and postoperatively [1]. Early cardiology consultation and continuation of cardio-protective drugs such as beta-blockers and statins are emphasized [5]. In this case, etomidate was chosen for its cardiovascular stability and minimal impact on coronary perfusion pressure. Fentanyl attenuated sympathetic surges, and sevoflurane provided myocardial preconditioning benefits demonstrated in multiple studies [6].

Anaesthetic goals include maintaining sinus rhythm, heart rate 60–80 bpm, mean arterial pressure ≥65 mmHg, and normoxia–normocapnia. Excessive depth of anaesthesia, rapid laryngoscopy, or uncontrolled pain can trigger ischaemia. Perioperative myocardial injury (MINS) remains a major cause of mortality even in asymptomatic patients; routine high-sensitivity troponin monitoring within 48 hr post-surgery is recommended by both AHA/ACC and ESC [2,7].

Fluid management must be tailored to maintain euvolaemia, as both hypovolaemia and fluid overload increase cardiac stress. Postoperative care should focus on haemodynamic optimization, oxygen delivery, and early mobilization. Invasive monitoring aids in early detection of haemodynamic deterioration and facilitates goal-directed therapy [8]. The role of vasopressors should favor norepinephrine or vasopressin to maintain perfusion without excessive tachycardia [9].

Dual antiplatelet therapy (DAPT) management is particularly complex. In patients with prior stenting, aspirin should be continued whenever possible; the second agent (clopidogrel or ticagrelor) may be withheld temporarily depending on bleeding risk and timing of stent placement [10]. Recent Canadian Cardiovascular Society (CCS) consensus (2023) suggests resuming P2Y12 inhibitors 24–48 hr postoperatively once haemostasis is secured [11]. Bridging strategies using cangrelor or glycoprotein IIb/IIIa inhibitors remain experimental and should be guided by cardiology.

A multidisciplinary approach involving anaesthesia, cardiology, and surgery is paramount. Modern perioperative algorithms emphasize dynamic risk reassessment, use of structured decision-making tools, and early detection of MINS using high-sensitivity assays. Our experience demonstrates that careful intraoperative monitoring, gentle laryngoscopy, balanced anaesthesia, and postoperative vigilance can lead to favourable outcomes even in this extreme-risk cohort.

Conclusion

Emergency surgery in the presence of ACS requires meticulous perioperative strategy aligned with current cardiovascular guidelines. Etomidate-based induction, vigilant haemodynamic management, and postoperative troponin surveillance are key to minimizing cardiac risk. Multidisciplinary coordination remains the cornerstone for optimizing outcomes in such high-risk surgical patients.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that names and initials will not be published and that efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

  • Writing Committee Members. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. J Am Coll Cardiol. 2024;83(7):1283–1365.
  • Halvorsen S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826–3924.
  • Smilowitz NR, et al. Perioperative myocardial infarction: Pathophysiology, diagnosis, and management. J Am Coll Cardiol. 2023;81(4):353–368.
  • Duceppe E, et al. Canadian Cardiovascular Society guideline on perioperative cardiac risk assessment and management. Can J Cardiol. 2023;39(2):137–156.
  • Lee TH, et al. The Revised Cardiac Risk Index for preoperative risk prediction. Circulation. 2023;148(5):412–421.
  • Kharasch ED, Avram MJ. Etomidate revisited: Pharmacology and clinical uses. Anesth Analg. 2021;133(6):1402–1414.
  • Devereaux PJ, et al. Myocardial injury after non-cardiac surgery (MINS): New evidence and implications. JAMA. 2024;332(10):951–963.
  • Shander A, et al. Perioperative haemodynamic optimization: Evidence and protocols. Anesth Analg. 2024;138(1):112–122.
  • Wijeysundera DN, et al. Vasopressor use in high-risk cardiac patients: A systematic review. Br J Anaesth. 2024;132(2):239–251.
  • Rossini R, et al. Perioperative management of antiplatelet therapy in patients with coronary stents. Eur Heart J. 2024;45(1):67–75.
  • Cleveland Clinic Journal of Medicine. 2024 ACC/AHA guideline updates for perioperative cardiovascular management: What’s new? Cleve Clin J Med. 2025;92(3):175–182.

 

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