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Anesthesia for the Patient with Cardiac Disease
TEXTCoexisting Disease · 10 min read
CAD, valve lesions, HF, arrhythmias. The 'cardiac patient for non-cardiac surgery' question family is heavily NBCRNA-tested.
After this lesson you can
2 min read7 sections- Risk-stratify cardiac patients using RCRI.
- Decide on stress testing or coronary intervention.
- Manage CHF + valvular disease intraop.
- Recall medication continuation/hold rules.
Preop cardiac risk stratification
Score ≥2 = elevated risk consider further testing.
ACC/AHA 2014 stepwise: emergent proceed.
Active cardiac condition (unstable angina, decompensated HF, severe valve disease, significant arrhythmia) optimize.
METs ≥4 (climb a flight of stairs) proceed.
METs <4 with elevated risk stress test only if will change management.
Coronary stents + DAPT
Drug-eluting stent: 6 months minimum (ideally 12 mo for first-gen DES; newer-gen 3-6 mo acceptable per ACC 2016).
Continue aspirin perioperatively if at all possible.
P2Y12 inhibitor: hold based on agent.
- proceed
- expect bleeding
- platelets only for surgical bleeding
Bridge with cangrelor (IV P2Y12) if very high-risk stent thrombosis profile.
Aortic stenosis
Severe AS = valve area <1.0 cm², gradient >40 mmHg, jet velocity >4 m/sPhysiology: fixed obstruction preload-dependent, sinus rhythm essential (atrial kick = 30-40% of CO), avoid tachycardia (subendo ischemia), avoid hypotension (coronaries perfuse off MAP minus LVEDP).
Anesthetic plan: maintain SVR (phenylephrine first-line), avoid spinal/epidural with sudden sympathectomy.
- 'fast
- full
- forward' — opposite of AS
Mitral stenosis + regurgitation
Keep slow, sinus rhythm, avoid hypoxia/hypercarbia (PVR rise).
MR: 'fast, full, forward' — avoid bradycardia (more time for regurg), maintain forward flow with reduced SVR.
Mitral valve prolapse — usually well-tolerated; avoid hypovolemia.
Heart failure
Avoid agents that depress contractility (high-dose volatile, propofol bolus).
Etomidate or low-dose ketamine for induction.
Maintain CPP with vasopressor.
Beta-blocker continued perioperatively.
Diuretic reduced morning of (volume management).
LVAD patients — no pulse, MAP via NIBP cuff Doppler or A-line, avoid acute preload drops, avoid sustained tachycardia, maintain RV function (avoid hypoxia, hypercarbia).
Arrhythmias + devices
Long QT — avoid prolonging agents (ondansetron, haloperidol, methadone, propofol minimally), maintain K + Mg, magnesium 2 g IV if torsades.
- identify device + dependency
- reprogram or magnet over device to disable ICD shocks for cautery
- bipolar cautery preferred
- monopolar return pad placed away from device
Pulmonary hypertension
- hypoxia
- hypercarbia
- acidosis
- hypothermia
- light anesthesia (sympathetic surge)
- N₂O (mild pulm vasoconstrictor)
- inhaled NO
- inhaled prostacyclin (epoprostenol/iloprost)
- milrinone
- dobutamine
RV failure is the killer — maintain CPP with norepinephrine/vasopressin (less PVR effect than phenylephrine).
Avoid Trendelenburg (R-heart strain).
Have ECMO conversation pre-induction for severe cases.
⚠ Common pitfalls
- Holding all beta-blockers — never; continue chronic BB to prevent rebound.
- Aggressive crystalloid in CHF — pulmonary edema risk.
- Spinal anesthesia in severe AS — relative contraindication.
- Skipping pre-op TTE in unexplained new murmur — could change management.
💎 Clinical pearls
- RCRI ≥3 + low functional capacity = consider stress testing.
- Severe AS: phenylephrine first-line for hypotension; preserve coronary perfusion.
- ACE-I/ARB hold morning of surgery is controversial — institutional preference.
- Continue statins peri-op — plaque-stabilizing effect protects.
Recap
- RCRI ≥3 + low functional capacity = consider stress testing.
- Severe AS: phenylephrine first-line for hypotension; preserve coronary perfusion.
- ACE-I/ARB hold morning of surgery is controversial — institutional preference.
- Continue statins peri-op — plaque-stabilizing effect protects.
Mark each section done to complete the module.