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Summary
This chapter discusses anesthesia in patients with cardiovascular disease. Multiple factors must be considered when choosing an anesthetic technique: the patient’s preferences, the requirements of the surgical procedure, and the patient’s underlying medical condition(s) (see accompanying Hurst’s Central Illustration). Almost all general anesthetics have cardiovascular adverse effects and also mask many of the symptoms of cardiovascular decompensation. Moreover, pharmacological reversal of nondepolarizing neuromuscular blocking drugs can lead to arrhythmias in patients with cardiovascular disease and has been associated with cardiac arrest in patients with prior heart transplants. Certain anesthetic techniques, such as neuraxial anesthesia, may be contraindicated in the presence of certain antithrombotic regimens. Spinal anesthesia is contraindicated in patients with severe valvular stenosis or hypertrophic obstructive cardiomyopathy but, with appropriate monitoring, cautious administration of epidural anesthesia may be performed safely in these patients. Inadvertent intravascular injection or absorption of local anesthetics can cause severe arrhythmias, including ventricular fibrillation and cardiovascular collapse. Additionally, epinephrine and phenylephrine may be added in small doses to prolong the duration of action of local anesthetics, but result in slight tachycardia and diastolic hypotension, which is undesirable in patients with certain cardiovascular diseases. With all forms of anesthesia, appropriate monitoring technology must be applied intraoperatively. The anesthesiologist should be prepared to manage hemodynamic alterations and analgesic requirements in the postoperative period.
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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.
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PREOPERATIVE EVALUATION
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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, ...