Incidence

Age group, per 1,000 (2):

• 65–74 years: 9.2 male, 4.7 female
• 75–84 years: 22.3 male, 14.8 female
• 85 years and older: 41.9 male, 32.7 female

Prevalence

Adults 20 and older: 5,800,000 in the US (3,100,000 males, 2,700,000 females) (2)

• In 2006, accounted for 1,106,000 hospital discharges in the US (3,4).
• Perioperative all-cause 30-day readmission is 17.1% versus 10.8% for coronary artery disease (CAD).

• One-year mortality rate: 1 in 5 (3,4)
• Any-mention death rate: 98.2 per 100,000 deaths; 103.7 for white males, 105.9 for black males, 80.3 for white females, 84.4 for black females
• Perioperative all-cause mortality: 8% versus 3.1% for CAD.

History

• Baseline functionality (7,8)
• History of CAD, cardiac surgery, abnormal blood pressure; NYHA or ACC/AHA classification.
• Diabetes and blood glucose levels
• Use of tobacco, alcohol, and illicit drugs.
• Pacemaker and internal cardiac defibrillator (ICD) settings and interrogation.

Signs/Physical Exam

• Vital signs, height, and weight (8)
• Tachypnea, rales, pleural effusions, cyanosis
• Resting tachycardia and S3 heart sound; jugular venous distension
• Hepatomegaly, ascites, peripheral/dependent edema

Labs/Studies

• Electrolytes, BUN, and creatinine (8)
• CBC
• TSH, liver function
• Chest x-ray (CXR) (cardiomegaly, pulmonary edema, pneumonia)
• ECG (myocardial infarction and ischemia, left ventricular hypertrophy (LVH), conduction abnormalities or dysrhythmias)
• Echocardiography (EF%, LV structure/function, valvular pathology)
• Digoxin level
• Brain natriuretic peptide (BNP) (for new diagnosis to risk stratify only)
• Pacemaker and ICD interrogation
• Cardiac catheterization, noninvasive testing

• Anxiolysis should be titrated cautiously; monitor for hypoxia.
• Beta-blockers should be continued perioperatively. Randomized controlled trials have shown improved outcome in high-risk cardiac patients by preventing arrhythmias and ischemia.

All types have been used successfully. Both general and neuraxial techniques result in sympatholysis in patients with high compensatory sympathetic tone; can result in profound hypotension that should be anticipated and treated aggressively.

• ASA standard monitors
• Invasive monitoring is dependent on the severity of disease, surgical procedure, and emergency surgery.
• Arterial lines can aid with beat-to-beat blood pressure monitoring and frequent lab draws. Worsening Alveolar-arterial (A-a) gradient or a-A ratio as well as metabolic acidosis/base excess can indicate worsening pulmonary edema, fluid overload, and/or myocardial pump or valvular dysfunction.
• Central venous monitoring can aid with assessing ventricular filling and fluid status. A pulmonary artery catheter can provide additional information of mixed venous oxygen saturation (an indicator of worsening cardiac output), systemic vascular resistance (SVR), and LVEDP; can guide and assess inotropic, vasodilator, and diuretic therapy intraoperatively and postoperatively.
• Transesophageal echocardiography (TEE) can aid with monitoring ventricular filling, ventricular wall motion, valve function, and EF. Limited by clinical expertise, availability, and intraoperative use.

• Both IV and inhalational agents can be utilized for induction, and should be titrated carefully.
• Propofol causes vasodilation and hypotension; consider lower doses, and more time for onset of action.
• Etomidate has favorable hemodynamic effects but can cause some decrease in blood pressure in patients with ventricular dysfunction or HF.
• Ketamine can be useful in the setting of poor ventricular function (EF <30%) due to its sympathomimetic effects. It also has the potential to cause negative inotropic effects in the patient with ventricular dysfunction or cardiomyopathy.
• Opioids, lidocaine, and other IV anesthetics can blunt the sympathetic stimulation with laryngoscopy and intubation to prevent tachycardia and HTN.
• High-dose opioids in combination with other IV anesthetics cause a dose-dependent cardiac depression likely due to blunting of the already elevated sympathetic tone.

• Both inhalational and/or IV balanced anesthesia techniques can be utilized; they include inhaled volatile and nitrous oxide, opioid, and neuromuscular blockers. Sympatholysis can be accentuated and compounded in patients with a high sympathetic tone, such as in HF patients. Therefore, it is important to consider smaller doses and to titrate to desired effects.
• Positive pressure ventilation (PPV) and positive end-expiratory pressure (PEEP) may decrease pulmonary congestion and improve arterial oxygenation (decrease atelectasis and shunting of alveolar–capillary units).
• Fluids should be carefully titrated to optimize preload (Frank–Starling curve) while avoiding RV and LV overload and pulmonary congestion.
• Since HF patients have down regulation of B1 receptors, a combination of inotropic agents with different mechanism of action may sometimes be needed (i.e., epinephrine + milrinone).

• Standard extubation criteria apply; however, patients may be less capable of meeting them.
• Prevent and immediately treat tachycardia, hypotension/HTN, and increased/decreased contractility if present. Hypotension can be a sign of myocardial ischemia and/or worsening HF.
• Supplemental oxygen should be administered.
• Treat shivering and hypothermia.