CHAPTER 34

ANAESTHESIA AND HEART DISEASE

Outline:

Heart failure

Hypertension

Myocardial ischaemia

Arrhythmias

Other cardiac conditions

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HEART FAILURE

Right heart failure

The signs are:
• Ankle oedema
• Elevated jugular venous pressure
• Enlarged and tender liver
• Third heart sound

Left heart failure

When the left side of the heart fails, there is congestion in the lungs.
Therefore the symptoms are respiratory. Dyspnoea is the main symptom,
first noted on exertion. Later attacks occur at night and finally the dyspnoea
persists even at rest. On auscultation of the chest fine or coarse crepitations
may be heard. It is important to find the underlying cause of the cardiac
failure, e.g. ischaemia, hypertension, valvular heart disease.

Anaesthesia
Patients with uncontrolled congestive heart failure (left heart failure) should
not be anaesthetised for routine surgery as there is a high perioperative
morbidity. They should be treated pre-operatively with:
• Oxygen.
• Diuretics, e.g. frusemide.
• Potassium supplements as indicated.
• Digoxin only if there is rapid atrial fibrillation.
• ACE inhibitors (angiotensin converting enzyme inhibitors), if
available.

Pre-operative management: Once the cardiac failure has been controlled, it

is safe for surgery to proceed. Frusemide can also be given IM depending
on the severity of the cardiac failure. The drugs for treatment of cardiac
failure should be continued right up to the morning of operation
In the urgent case when it is not possible to spend time treating the cardiac
failure, a regional anaesthetic may be preferable to a general anaesthetic. A
spinal might be reasonable if aortic stenosis and unstable angina are
excluded. If a general anaesthetic is essential it must be given very
carefully.

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Intra-operative management: If a general anaesthetic is used, the
principles are:
• Give small doses of drugs
• Air/oxygen/volatile ± relaxant or a ketamine technique would be
reasonable
• Give a higher inspired oxygen concentration to avoid hypoxia
• Avoid hypotension
• Avoid fluid overload
• Give intermittent positive pressure ventilation.

HYPERTENSION

This is an increasing problem in anaesthesia. Hypertension, when it occurs

in younger people can be due to an underlying disease, e.g. renal, endocrine,
etc. In all cases prolonged hypertension, especially if untreated, affects
various organs, e.g. the heart, kidneys. These patients are prone to heart
failure and renal failure, because they cannot compensate for hypotension,
hypoxia or hypercarbia. Some may be on anti-hypertensive drugs. It is now
accepted that:
• All hypertensive patients should be treated before elective surgery and
their blood pressure stabilised to a diastolic pressure of 90-100 mmHg.
• Patients are kept on their anti-hypertensive drugs right up to the time of
operation.
• Patients presenting for elective surgery with untreated hypertension
with a diastolic pressure > 115 mm Hg on at least two readings should
be cancelled and prescribed treatment.

Points of importance to the anaesthetist

Patients on anti-hypertensive drugs cannot compensate in the usual way for
the stress of anaesthesia. Things to monitor closely are:
− Anaesthetic drugs and their side effects
− Blood loss
− Changes in position
− IPPV
− Avoid hypoxia
− Avoid hypercarbia.
The same precautions, as described for patients with myocardial ischaemia
or CCF must be used for hypertensive patients.

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MYOCARDIAL ISCHAEMIA

Myocardial ischaemia, or damage to the myocardium, results if the arteries

supplying the heart muscle become narrowed or blocked. The blood supply
to the heart muscle is therefore reduced and ischaemia results. Myocardial
ischaemia must be carefully evaluated before surgery. An ECG should be
done.
If this shows evidence of a myocardial infarct and the surgery is elective,
then 6 months should elapse before the operation. If the surgery is semi-
urgent and has to be done under a general anaesthetic then a minimum of 3
months should still elapse. Urgent surgery is carried out in the context of
risk against benefit. Even 6 months following the infarct, the mortality rate
is higher.
If the ECG shows evidence of myocardial ischaemia only, without damage
or death of the heart muscle (i.e. no infarction) then anaesthesia still carries
certain risks because these patients are very liable to go into heart failure
and /or develop an arrhythmia, or progress to infarction.

Anaesthetic technique
The same principles and techniques as outlined for patients with congestive
heart failure should be followed in patients with myocardial ischaemia.
• Stabilise the patient as much as possible preoperatively i.e. nitrates,
beta-blockers
• Give small doses of drugs, especially myocardial depressants, e.g.
thiopentone, halothane, etc.
• Use a high inspired concentration of oxygen.
• Have good intravenous access.
• Avoid hypoxia, hypercarbia and swings in blood pressure. These
patients are more liable to hypotension on account of their drug
treatment, e.g. beta-blockers.
• Avoid fluid overload.
• Use a relaxant technique with IPPV.

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 ARRHYTHMIAS

The dangers of arrhythmias under anaesthesia are:

• Myocardial ischaemia as a result of a rapid heart rate
• Ischaemia of the brain and kidney
• Myocardial infarction
• Cardiac failure
• Ventricular fibrillation (cardiac arrest)
• Thrombo-embolism.

The following are arrhythmias which should be treated before elective

surgery:
• Sinus tachycardia. Find the cause and treat it first.
• Sinus bradycardia, especially if there is an associated fall in cardiac
output and blood pressure.
• Atrial tachycardia )
Atrial flutter ) if the rate is above 100/min.
Atrial fibrillation )
• Ventricular ectopics (if greater than 5 per minute, or multifocal, or
close to the preceding T-wave with the risk of the R on T
phenomenon).

OTHER CARDIAC CONDITIONS

• Rheumatic heart disease. In the acute stage, general anaesthesia is
contraindicated. In rheumatic valvular heart disease, give pre-operative
cover with antibiotics to protect against endocarditis and observe the
safety principles outlined earlier.
• Congenital Heart Disease. Here too give antibiotic cover
pre-operatively.

Suggested regime of antibiotic cover for patients at risk of endocarditis

Amoxycillin 3g orally 4 hours before surgery or 1g IV at induction followed

by amoxycillin 3g orally 6 hours post-operatively
OR
(for patients who are allergic to penicillin)
Vancomycin 1g by IV infusion over 1-2 hours followed by gentamicin
120mg IV at induction.
Not all of these antibiotics will be available in many hospitals but should be

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used if possible.

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