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 the others. The approach should emphasize a continuum of care from the preoperative evaluation through the extended postoperative period.
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 et al1 introduced the Cardiac Risk Index Score (CRIS) to guide more quantitatively the assignment of cardiac risk in patients undergoing noncardiac surgery. This study had a major impact because clinicians concluded that improvements in factors such as congestive heart failure symptoms and general medical condition would decrease cardiac risk. Although the predictive value of the CRIS remains controversial,2 the emphasis on preoperative optimization continues and is reviewed in Chap. 87. The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines published "Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery" that were last updated in 2009.3 The algorithmic approach to preoperative evaluation described in these guidelines is valuable in that more consistent clinical approaches have emerged. The information derived from the clinical cardiac evaluation should provide answers to the following questions:
Is there a need for emergency noncardiac surgery?
Are there "active cardiac conditions" (previously known as "major risk factors")?
What is the cardiac risk of the planned surgery?
What is the functional capacity of the patient?
Does the patient have "clinical risk factors" (formerly known as "intermediate risk factors")?
The preoperative assessment that is of particular value to the anesthesiologist regarding choice of anesthesia technique and administration of anesthetic agents can be summarized as follows:
What is (are) the clinically significant pathologic condition(s) affecting the cardiovascular system?
Are further diagnostic studies required prior to elective surgery?
Will the patient derive benefit from delaying surgery to optimize preoperative medical therapy?
Should there be perioperative antithrombotic therapy?
What is the regimen of preoperative cardiovascular medications that should be continued through the perioperative period? Should β-blockers or statins be started?
What is the specific device information regarding the patient's pacemaker or automatic implantable cardioverter-defibrillator (AICD), and what are the recommendations regarding pacemaker/AICD programming in the perioperative setting?
A cogent and legible summary of the pertinent clinical, laboratory, radiologic, echocardiographic, radionuclide, and cardiac catheterization data comprises the ideal cardiac consultation for the anesthesiologist. With the benefit of this information, the two specialties can make intelligent decisions regarding the ...