ANAESTHETIC MANAGEMENT OF ISCHAEMIC HEART DISEASE FOR NON-CARDIAC SURGERIES 1 Managing Peri-Operative Ischaemia: Strategies for Preventing Myocardial Infarction in High-Risk Patients Indunil Karunarathna 1 , Sau Bandara 1 , Asoka Jayawardana 1 , Kapila De Alvis 1 , P Gunasena 1 , T Hapuarachchi 1 , U Ekanayake 1 , S Rajapaksha 1 , K Gunawardana 1 , P Aluthge 1 , S Gunathilake 1 1. Ministry of Health / Teaching Hospital Badulla / University of Colombo. Abstract: The incidence of ischaemic heart disease (IHD) is on the rise, and a growing number of patients with IHD, both with and without prior interventions, are presenting for non-cardiac surgical procedures. These patients face an elevated risk of perioperative complications, including myocardial ischaemia, myocardial infarction (MI), conduction disturbances, and increased morbidity and mortality. The risk is particularly high in patients with a recent MI or unstable angina. It is crucial for anaesthesiologists to understand the pathophysiology of IHD and to conduct thorough evaluations to optimize perioperative management. This review explores current practices and guidelines for the evaluation, risk stratification, and management of these patients. We conducted a comprehensive search on PubMed using terms such as "ischaemic heart disease," "anaesthesia," "perioperative," and "anaesthetic implications" to gather relevant literature and synthesize key findings. Keywords: Ischaemic Heart Disease (IHD), Perioperative Management, Myocardial Ischaemia, Anaesthesia, Risk Stratification, Non-Cardiac Surgery Key Points Increasing Incidence of IHD: There is a notable increase in the incidence of IHD globally, with a significant impact on perioperative outcomes in non-cardiac surgeries. High-Risk Population: Patients with recent MI or unstable angina are at heightened risk of perioperative complications, including myocardial ischaemia and MI. Comprehensive Evaluation: Thorough preoperative evaluation and risk stratification are essential for optimizing the perioperative management of patients with IHD. Guideline Adherence: Adhering to established guidelines for perioperative management can help mitigate risks and improve patient outcomes. Introduction Ischaemic heart disease (IHD) is a leading cause of morbidity and mortality worldwide, with its incidence continually rising. In the United States alone, approximately 25 million patients undergo surgery annually, of which an estimated 7 million are considered to be at high risk for IHD. According to Goldman et al., there are between 500,000 and 900,000 myocardial infarctions (MIs) globally each year, with mortality rates ranging from 10% to 25%. The number of patients with coronary artery disease (CAD), with or without prior interventions, presenting for non-cardiac surgery has also increased. These patients face significant perioperative risks, including myocardial ischaemia, MI, cardiac failure, arrhythmias, cardiac arrest, and elevated morbidity and mortality, particularly in those with recent MI or unstable angina requiring urgent or emergency surgery. In light of these challenges, it is imperative for anaesthesiologists to possess a comprehensive understanding of the pathophysiology of IHD and to engage in thorough preoperative evaluation and risk stratification. This review synthesizes the current literature and guidelines on the perioperative management of patients with IHD, highlighting best practices and strategies to optimize patient outcomes. We conducted an extensive PubMed search using combinations of terms such as "ischaemic heart disease," "anaesthesia," "perioperative," and "anaesthetic implications" to gather relevant studies and guidelines. Pre-Operative Evaluation The primary objective of pre-operative evaluation is to assess the patient’s current medical condition, develop a clinical risk profile, determine the need for additional tests, address modifiable risk factors, and plan the management of any cardiac conditions during the peri-operative period. History and Physical Examination: A thorough history and physical examination are critical. Key elements to investigate include: History of Cardiac Conditions: Look for symptoms of angina pectoris, recent myocardial infarction (MI), unstable angina, and cerebrovascular disease. Prior Myocardial Infarction: According to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, the risk of a peri-operative cardiac event is high within 6 weeks of an acute MI, as this period corresponds to the typical healing time for the infarcted myocardium. The risk is considered intermediate from 6 weeks to 3 months and may extend beyond 3 months if complications such as arrhythmias or ventricular dysfunction are present. Patients who have undergone coronary revascularization within the last 5 years and are asymptomatic generally have low perioperative risk and may proceed with surgery without further evaluation. Utilizing pre-operative questionnaires, particularly computer-