Department of Anaesthesia

University of Cape Town

Cardiovascular Disease and Anaesthesia

Cardiovascular disease; namely hypertension, valvular heart disease and ischaemic heart disease;
are common and are a major cause of peri-operative morbidity and mortality.
The adrenergic response to surgery, haemodynamic effects of anaesthesia (vasodilatation and
myocardial depression), endotracheal intubation, positive pressure ventilation, blood loss, fluid shifts
and body temperature; impose additional burdens on an already compromised cardiovascular system.
The aims of anaesthesia for patients with cardiovascular disease are to:
1) Identify their disease and baseline functional level; optimising the patient as best as possible
2) Monitor appropriately and support the cardiovascular system to prevent further deterioration
3) Administer appropriate anaesthesia to maintain circulation and prevent target organ damage

Hypertension
Hypertension is associated with significant morbidity due to target organ damage, e.g. left ventricular
hypertrophy, cardiac failure, coronary artery disease, renal failure and cerebrovascular events.

Aetiology
 Idiopathic (Essential or benign hypertension)
o Generally mild and slowly progressive with eventual end-organ damage
 Secondary
o Rare  Coarctation of the aorta
Renal disease
Endocrine abnormalities
o Aggressive end-organ damage occurs early
o The primary disease, e.g. phaeochromocytoma, may impact severely on anaesthesia

Anaesthesia concerns
Risk of anaesthesia in hypertensive patients include:
 Cerebrovascular events
 Myocardial ischaemia and / or infarction; cardiac failure
 Renal failure
 Other end-organ damage, e.g. encephalopathy
Poor blood pressure (BP) control or suboptimal therapy increases risk; and is highest in uncontrolled,
undiagnosed or untreated patients. A well managed / controlled patient has a normal risk.
Diastolic BP > 120 mm“Hg” should be controlled and elective surgery postponed for 2 weeks.
Left ventricular remodelling and normalisation of the shifted auto-regulatory curve will take > 6 months.
Exaggerated swings in BP can be precipitated by sympathetic stimulation (intubation, surgery),
vasodilatation (anaesthesia) or blood loss. Hypotension is more dangerous than hypertension.
Antihypertensive agents can have several consequences:
 Diuretics may lead to fluid depletion and electrolyte disturbances (especially hypokalaemia)
 Beta-blockers are negatively inotropic and slow the heart rate, i.e. decrease the cardiac output
 Calcium channel blockers cause hypotension
 ACE-inhibitors can lead to exaggerated intra-operative hypotension and irritable airways

Peri-operative management
Anxiety is a cause of an elevated blood pressure, but ‘white coat’ hypertension is not necessarily a
benign disease. Note the BP trend on the ward chart, and take the BP yourself. Look for end-organ
damage (electrolytes and urea, functional status, ECG, CXR).
Ascertain the patient’s baseline level of functioning in any chronic cardio-respiratory disorder.
Anti-hypertensive medication should be continued peri-operatively. Sedative premeds are helpful.
Careful BP control is important intra-operatively and should be maintained within 25 % of the starting
pressure, avoiding a so-called ‘alpine trace’. This can be achieved by pre-empting noxious stimuli,
e.g. intubation; administering adequate analgesia, and avoiding a light plane of anaesthesia. Spinals
and epidurals are useful but anticipate the relative hypovolaemia as result of a decrease in
sympathetic tone associated with regional techniques.
 Cardiovascular disease and anaesthesia

Ischaemic heart disease (IHD)

IHD is the main cause of peri-operative deaths. Surgery and anaesthesia may aggravate or
precipitate an acute coronary syndrome. Peri-operative myocardial infarctions have a 50 % mortality.

Risk
Any patient who has had a coronary artery bypass graft (CABG) in the last five years and is symptom
free can be considered to have a normal pre-operative risk. Patients with a good effort tolerance,
i.e. can walk up ≥ 2 flights of stairs, without stopping, also have normal anaesthetic risks.
Patients with stable angina and / or a poor effort tolerance, are at a moderately increased risk.
Acute coronary syndrome, i.e. unstable angina or recent myocardial infarction, is associated with an
extremely high anaesthetic risk. Elective surgery should be postponed for 6 months after a
myocardial infarction.
Patients who have had a coronary artery stent placed must be referred to cardiology. These
patients are at a great risk of stent occlusion (and dying!) if anti-platelet therapy is inappropriately
stopped. This is dependent on the type of stent and when it was placed.

Assessment
Assess functional capacity. Early fatigue or dyspnoea suggests compromised ventricular function.
Note that diabetic patients may have “silent” angina and infarcts.

Special investigations
Resting ECG is not very sensitive and has many false negatives.
Stress testing is more sensitive.
Coronary angiography will assess the requirement for coronary artery bypass surgery, if this is
considered necessary by the clinical assessment of the patient.

Management
Pre-operative:
Assess severity of disease and adequacy of therapy. Prescribe a good premedicant to avoid anxiety-
driven release of catecholamines and the resultant tachycardia, which could worsen myocardial
ischaemia. Continue treatment, especially β-blockers. Consider increasing the dose of β-blocker (or
adding a β-blocker) peri-operatively to decrease hypertension and tachycardia with anaesthesia.
Intra-operative:
Minimise myocardial ischaemia by avoiding tachycardia, hypotension and systolic hypertension.
Coronary perfusion relies on a slow heart rate (long diastole) and good diastolic pressure. Watch
blood loss and maintain a haemoglobin ≥ 10 g dl-1 to optimise O2 delivery to myocardium.
Monitor s-T segments for intra-operative ischaemia.
Anaesthetic agents of choice:
 Etomidate for induction
 Isoflurane is often used for maintenance (the “coronary steal” phenomenon is theoretical)
Halothane has advantages – ↓ HR, negative inotropy –  ↓ O2 demand; but is dysrhythmic
 Vecuronium or rocuronium for muscle relaxation (pancuronium causes a tachycardia)
 Analgesia
o Fentanyl for analgesia; or the other synthetic opiates such as sufentanil or alfentanil are
cardiovascularly stable – Titrate to effect
o Remifentanil may cause hypotension and bradycardia – Be careful
o Morphine is a good long acting analgesic – Give small increments and titrate to effect.
Vasodilatation is minimal and should not drop the BP in small doses
o Non-opiate drugs are a good alternative
IV paracetamol (Perfalgan®)
IV NSAID’s (esp. COX-2 inhibitors) should be avoided in IHD as they increase the risk
of a cardiovascular event
Local anaesthetic infiltration and regional anaesthesia are excellent alternatives if
appropriate for the type of surgery
Postoperative:
Most peri-operative infarcts occur within 48 - 72 hours postoperatively, with a 40 - 60 % mortality.
Therefore this is the most critical period to monitor. Ensure adequate analgesia and supplemental
oxygen administration if required.

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 Cardiovascular disease and anaesthesia

Valvular heart disease (VHD)

Valvular heart disease is common in South Africa; in fact, we have the highest incidence world-wide
due to rheumatic fever. Unfortunately, this is more common in the lower socio-economic groups.
Management will depend on the valve involved, the severity of the lesion and whether it is stenotic or
regurgitant. It will also depend on whether the VHD is complicated by the presence of a non-sinus
rhythm (atrial fibrillation is common), pulmonary hypertension, bacterial endocarditis, cardiac failure
and / or the presence of coronary artery disease.
The dominant lesion in mixed aortic or mitral valve disease should be determined and managed
accordingly. Antibiotic prophylaxis is indicated in patients with previous valvular surgery, previous
bacterial endocarditis and surgical shunts.
Patients who have previously undergone heart valve surgery (replacement or repair) and now present
for unrelated surgery need to be referred to cardiology. Advice must be sought in respect of cardiac
reserve, peri-operative management and management of anticoagulation (esp. mechanical valves).

Aortic stenosis
A fixed cardiac output exists, i.e. the stroke volume cannot increase; so maintaining the systemic
vascular resistance (SVR) and a slow heart rate (preferably in sinus rhythm) to allow time for
ejection, is important.
Maintenance of the SVR and afterload also ensures adequate coronary perfusion, which is particularly
important, as the left ventricle is hypertrophied.
Spinal or epidural anaesthesia is contra-indicated because it decreases the SVR.

Aortic incompetence
A fall in the SVR will decrease the regurgitant flow and increases in SVR from pain or vasopressors
must be avoided.
Maintain the heart rate at 80 - 100 beats min-1 with a good preload to reduce the time for regurgitant
flow.
“Full, fast and forward”

Mitral stenosis
This is also a fixed cardiac output state.
Patients are at risk of developing pulmonary oedema that may be precipitated by tachydysrhythmias,
particularly atrial fibrillation (AF).
The tachycardia decreases the diastolic time and left ventricular filling is further diminished by the loss
of atrial systole or ‘kick’.
Thus keep the heart rate slow and treat tachycardia aggressively.

Mitral incompetence
This lesion should also be kept “full, fast and forward”, but avoid fluid overload.
75 % of these patients are in atrial fibrillation and may be on therapy for rate control, e.g. digoxin.
If on digoxin, check the electrolytes and keep the potassium > 4 mmol l-1.
Patients in AF are routinely anticoagulated with warfarin, and the INR must be checked and allowed to
recover to < 1,5 before surgery.

Cardiac failure
Cardiac failure is an independent major risk factor for anaesthetic morbidity and mortality, so ideally
surgery should be postponed until the patient is out of failure.
Treat the cause of failure and optimise medical therapy. Fluid status is important, and a central
venous pressure (CVP) line may be an aid in the assessment of fluid status and for the administration
of inotropes (dobutamine and / or adrenaline).
Maintain a good preload (avoiding overload), good inotropy and a faster rate, and aim to reduce
afterload. Avoid drugs that are myocardial depressants. Avoid hypoxia, hypercarbia and acidosis
which all worsen contractility.
Regional anaesthesia, in the form of spinals or epidurals, may be used with caution; but the patient
may not tolerate the significant drop in blood pressure with the sympathetic blockade. Be prepared to
use a vasoconstrictor if necessary (phenylephrine or ephedrine).
Peripheral nerve blocks, and avoiding the use of a general anaesthetic, are a good option if
appropriate for the type of surgery.
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 Cardiovascular disease and anaesthesia

Dysrhythmias
Dysrhythmias during anaesthesia are common. They are usually benign and short-lived.
Try to identify a cause (pain, ↓ PaO2, ↑ PaCO2, halothane, drugs, electrolytes) and treat the cause.
Assess the effect on haemodynamics by keeping a close eye on the BP and pulse volume.
If cardiovascularly unstable; the dysrhythmia may respond to direct current (DC) cardioversion with
the “sync” button switched on as you cardiovert. The patient should be sedated if not already under a
general anaesthetic.
An alternative to electricity is amiodarone 300 mg loading dose over 1 hour; but if very unstable may
be administered rapidly over a few minutes for both supraventricular and ventricular tachycardias.
Lignocaine 1 - 2 mg kg-1 IV has been used for ventricular dysrhythmias.
Anaesthesia may aggravate / precipitate / cure pre-existing dysrhythmias. Patients with pre-existing
heart block may have a pacemaker in situ, or may require insertion of one prior to surgery.

If the patient has a pacemaker in situ, ascertain when it was inserted and the indication. Refer to
cardiology if there is any indication that the device may not be functioning properly. Pacemakers
should be checked annually by a clinical technologist to ensure that it is in good working order and to
determine the remaining battery life. The patient should be able to tell you when it was last checked.
If the pacemaker has not been checked in the last year; postpone elective surgery until this is done.
A chest X-ray will show where the generator is, may reveal loose or “fractured” leads coming off the
box and whether it is bi- or mono- polar or multi-chamber.
An ECG may show pacing spikes if the patient is pacing-dependent.
If the patient has an implantable cardioverter-debrillator pacemaker, which has the ability to administer
a shock in the case of lethal tachydysrhythmias; this function should be disabled as the pacemaker
may misinterpret the interference from surgical diathermy as a dysrhythmia during surgery.
Surgical cautery or diathermy may also interfere with a normal pacemaker function. Bipolar diathermy
is advised; but if unipolar, then diathermy plate must be as far away from the pacemaker as possible.
Magnets are not used routinely, but some pacemakers (ascertain this pre-operatively) will switch to a
“fixed-rate (VOO) mode” when a magnet is applied. Only do this if aware of the response that the
pacemaker has to a magnet, and the patient is haemodynamically unstable despite these precautions.

What are the risks with cardiovascular disease?

Primary and secondary risk factors for peri-operative cardiac morbidity
Primary risk factors

Congestive cardiac failure (CCF) Dysrhythmias, prolonged ICU stay post-op,

sudden death

Acute coronary syndrome Peri-operative infarction, dysrhythmias, heart

failure

Intra-coronary stent Stent occlusion if anti-platelet medication stopped

Recent myocardial infarction (MI) High risk of re-infarction within 3 months. Risk
reduced to < 2 % if surgery delayed for 6 months.

Uncontrolled hypertension Dysrhythmias, CCF, stroke

Dysrhythmias with underlying myocardial CCF, myocardial ischaemia

disease

Secondary risk factors

Diabetes mellitus, smoking, obesity, Increased risk of coronary artery disease,

hypercholesterolaemia, increased age, myocardial ischaemia and peri-op MI and sudden
peripheral vascular disease death
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