CHAPTER 99: ANESTHESIA AND THE PATIENT WITH CARDIOVASCULAR DISEASE

INTRODUCTION

Anesthetizing patients with cardiovascular disease is one of the greatest challenges facing the anesthesiologist. The constellation of anesthetic drug effects, the physiologic stresses of surgery, and underlying cardiovascular diseases complicate and limit the choice of anesthetic techniques for any particular procedure. The anesthesiologist’s approach to the patient with cardiovascular disease is to select agents and techniques that will optimize the patient’s cardiopulmonary function. The perioperative management of a patient with cardiovascular disease requires close cooperation between the cardiologist/internist, surgeon, and anesthesiologist. Each specialist has a unique knowledge base that complements that of the others. The approach should emphasize a continuum of care from the preoperative evaluation through the postoperative period.

PREOPERATIVE EVALUATION

The assessment of cardiac risk and preoperative optimization of the patient’s cardiovascular status are the traditional goals of the preoperative evaluation of patients with cardiovascular disease. In 1977, Goldman and associates¹ introduced the Cardiac Risk Index Score (CRIS) to guide more quantitatively the assignment of cardiac risk in patients undergoing noncardiac surgery. According to the CRIS, the risk for adverse cardiac events increases with the number of preexisting conditions such as heart failure, ischemic disease, cerebrovascular disease, diabetes, chronic kidney disease, as well as the type of planned procedure. This study had a major impact because clinicians concluded that preoperative improvements in some of these factors, such as heart failure symptoms, would decrease cardiac risk. Cardiac risk assessment continues to evolve, and is reviewed in detail in Chapter 98. The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines published “Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery,” which was last updated in 2014.² Preoperative evaluation should include a thorough history and physical examination, assessment of surgery specific risks, and advanced testing based on the severity of underlying cardiac disease as outlined in the AHA guidelines. The algorithmic approach to preoperative evaluation described in these guidelines is valuable in that more consistent clinical approaches have emerged (see Chapter 98, Fig. 98–1).

Specifically, the information derived from preoperative cardiac evaluation should address the following points:

1. Urgency assessment: If this is an emergency procedure, proceed to operating room and attempt risk modification (ie, surveillance/monitoring).

2. If surgery is not urgent, assess patient for signs of “active cardiac conditions.” These include unstable “acute” coronary syndrome (ACS) or recent myocardial infarction, decompensated heart failure, severe valvular disease, and significant arrhythmia. If present, consider further evaluation and treatment as per AHA guidelines before surgery.

3. In chronic, less severe cardiac disease (no active cardiac conditions), surgery-related risk assessment suggests advancing to surgery in low-risk surgical procedures.

4. If surgery-related risk is intermediate or high, functional status can give invaluable information about the cardiac reserve in response to surgery-related stress (eg, large fluid shifts, sudden hemodynamic changes). Functional capacity is described using metabolic equivalents (METs); one MET is the oxygen consumption of a 70-kg, 40-year-old man at ...