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PATIENT CASE

A 78-year-old man, who is treated by calcium channel blockers for arterial hypertension (HTN), has just met an anesthesiologist before hip replacement. He has no diabetes, has never smoked, and used to be a runner. Because of hip arthritis, the patient’s activities are limited (barely walks, lives in a 1-floor house, does not do gardening anymore) and his wife is taking care of all the housekeeping. The patient reports a nocturnal dyspnea. The clinical examination revealed a blood pressure of 148/69 mm Hg, a heart rate of 72 beats/min, and no sign of cardiac failure. The blood chemistry reveals a normal renal function, hemoglobin levels are 14 g/dL, and brain natriuretic peptide (BNP) levels are 350 pg/mL. The anesthesiologist has advised the patient to consult a cardiologist.

This case demonstrates a situation where the anesthesiologist and cardiologist should work together, prior to surgery, to assess the status of a patient and discuss perioperative management. In fact, this patient is about to undergo a surgery that is associated with high risk of complications by major cardiac events, such as acute heart failure (HF). Although he has few cardiac risk factors, his functional activity is not assessable and nocturnal dyspnea associated with increased plasmatic BNP levels raises the suspicion of an unknown HF that must be explored. Hence, in this case, it is recommended to perform an electrocardiogram (ECG) and a transthoracic echocardiography (TTE). Additional tests, such as a stress testing, will be discussed depending on the results of the first exams. The persistent high blood pressure and the probable HF necessitate reassessing the patient’s current medical treatment and considering treatment by beta blockers, if the procedure can be postponed for 3 to 6 months.

EPIDEMIOLOGY

  • HF is a complex clinical syndrome that can result from a variety of lesions of the myocardium, pericardium, heart valves, or great vessels as well as metabolic abnormalities, which leads to an impairment of ventricular relaxation, ejection, or both.1

  • HF can be classified in 4 stages, from A (patients at high risk for HF, without symptoms of HF) to D (refractory HF).1

  • The incidence of HF increases with age. As the population is aging, and the therapeutics of HF is improving, the number of HF patients keeps raising, with an estimated 50% increase in the number of new patients with HF every year in 15 years.2

  • Concomitantly, the number of surgical procedures performed yearly is increasing, especially in the elderly, with more than one-third of the procedures being performed in patients who are age 65 years and older.3

  • Hence, HF is more and more often encountered in the perioperative settings.

HEART FAILURE IS A MAJOR RISK FACTOR THAT INCREASES PERIOPERATIVE MORBIDITY AND MORTALITY

  • Despite improvements in perioperative care, cardiac complications are the leading cause of postoperative deaths.

  • Because HF is a significant risk for perioperative morbidity ...

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