Anesthesia for Patients with Cardiovascular Disease
Cardiovascular diseases—particularly hypertensive, ischemic, congenital, and valvular heart disease— are among the medical illnesses most frequently encountered in anesthetic practice and are a major cause of perioperative morbidity and mortality. Management of patients with these diseases contin-ues to challenge the ingenuity and resources of the anesthesiologist. The adrenergic response to surgical stimulation and the circulatory effects of anesthetic agents, endotracheal intubation, positive-pressure ventilation, blood loss, fluid shifts, and alterations in body temperature impose additional burdens on an often already compromised cardiovascular sys-tem. Most anesthetic agents cause cardiac depres-sion, vasodilatation, or both. Even anesthetics that have no direct circulatory effects may cause appar-ent circulatory depression in severely compromised patients who are dependent on the enhanced sym-pathetic activity characteristic of heart failure or acute blood loss. Decreased sympathetic activity as a consequence of the anesthetized state can lead to acute circulatory collapse.
Good anesthetic management of patients with cardiovascular disease requires a thorough knowl-edge of normal cardiac physiology, the circulatory effects of the various anesthetic agents, and the pathophysiology and treatment of these diseases. The same principles used in treating cardiovascular diseases in patients not undergoing surgery should be used perioperatively. In most instances, the choice of anesthetic agent is not terribly important; on the other hand, knowing how the agent is used, understanding the underlying pathophysiology, and understanding how the two interact are critical.
Patients with severe cardiovascular illnesses commonly undergo both cardiac and noncardiac sur-gery. The American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA), have issued numerous guidelines related to the management of patients with heart disease, and many of their recommendations are relevant to patients undergoing anesthesia and invasive proce-dures. Because guidelines change as new evidence becomes available, anesthesiologists are advised to review the AHA website for current evidence-based indications for the management of heart disease.