The optimization of patients with cardiac disease before anesthesia and surgery is critical for reducing perioperative morbidity and mortality. The physiological stress of anesthesia and surgery can precipitate major cardiac events, particularly in individuals with preexisting cardiovascular disease. Effective preoperative preparation includes comprehensive assessment, risk stratification, medical optimization, and planning for perioperative management. Risk assessment tools such as the Revised Cardiac Risk Index (RCRI) are widely used to identify patients at increased risk for myocardial infarction, heart failure, arrhythmia, or cardiac death during surgery, allowing clinicians to tailor interventions accordingly (1).
To determine a strategy for optimization, patients should undergo a thorough physical and cardiovascular history examination, supplemented by diagnostic testing, including electrocardiography and echocardiography when indicated by pre-existing cardiac conditions and/or results from their physical exam. Functional capacity remains a strong predictor of perioperative risk, and patients with poor exercise tolerance may require non-invasive stress testing to assess for significant coronary artery disease. Medical therapy is a cornerstone of preparation, with beta-blockers, statins, and angiotensin-converting enzyme inhibitors forming the mainstay for patients with coronary artery disease or heart failure. Careful adjustment of medications can help minimize the risk of ischemic events and maintain hemodynamic stability during surgery (2).
Patients with heart failure, particularly those with reduced ejection fraction, require special attention to volume status, electrolyte balance, and optimization of cardiac output. Preoperative echocardiographic assessment provides valuable information on ventricular function, valvular abnormalities, and pulmonary pressures, which can inform intraoperative monitoring and fluid management strategies. Maintaining a delicate balance to prevent both fluid overload and hypoperfusion is essential to avoid exacerbation of cardiac dysfunction during the perioperative period (2).
Arrhythmias, especially atrial fibrillation, must be treated preoperatively to avoid hemodynamic instability during anesthesia. Rate control with beta-blockers or calcium channel blockers and appropriate anticoagulation management are essential elements of preoperative planning. Decisions regarding continuation or interruption of anticoagulation must carefully balance the risks of thrombosis versus bleeding. The use of bridging anticoagulation with low-molecular-weight heparin may be indicated in select high-risk patients, although the need for this practice has been questioned in recent guidelines (3).
Patients with congenital heart disease represent a unique subset that requires careful individualized planning. Even small hemodynamic changes can have profound effects in these patients. Multidisciplinary collaboration between cardiology, anesthesia, and surgical teams is essential to ensure optimal outcomes. Preoperative imaging, tailored anesthetic approaches, and readiness for advanced hemodynamic monitoring are integral to minimizing perioperative complications. Specialized strategies, including maintenance of preload, avoidance of increased pulmonary vascular resistance, and careful selection of anesthetic agents, are key considerations in this population (4).
In addition to disease-specific considerations, general principles such as smoking cessation, control of hypertension, glycemic control in diabetic patients, and treatment of anemia should be addressed in the preoperative period. Systematic identification of modifiable risk factors may further reduce perioperative cardiac events. Postoperative monitoring for myocardial injury, particularly by monitoring troponin levels in high-risk patients, has been associated with improved detection and management of perioperative myocardial infarction (3).
In cases where cardiac optimization cannot be achieved before anesthesia and surgery, postponement of elective surgery should be considered. Ultimately, preoperative optimization is a dynamic and patient-specific process that requires thorough assessment, evidence-based medical management, and interdisciplinary coordination to achieve the best possible outcomes for patients with cardiac disease undergoing anesthesia and surgery.
References
- Guasti L, Fumagalli S, Afilalo J, et al. Cardiovascular diseases, prevention, and management of complications in older adults and frail patients treated for elective or post-traumatic hip orthopaedic interventions. Eur J Prev Cardiol. Published online January 15, 2025. doi:10.1093/eurjpc/zwaf010
- Iaconi M, Maritti M, Ettorre GM, Tritapepe L. Echocardiographic evaluation in patient candidate for liver transplant: from pathophysiology to hemodynamic optimization. J Anesth Analg Crit Care. 2024;4(1):75. Published 2024 Nov 14. doi:10.1186/s44158-024-00211-0
- Wang MK, Sabac D, Sadhak R, et al. Management of Patients with Myocardial Injury After Noncardiac Surgery: A Retrospective Chart Review. CJC Open. 2024;7(1):103-109. Published 2024 Oct 11. doi:10.1016/j.cjco.2024.10.004
- Müller M, Lurz F, Zajonz T, et al. Perioperative anesthetic management of patients with hypoplastic left heart syndrome undergoing the comprehensive stage II surgery-A review of 148 cases. Paediatr Anaesth. 2024;34(12):1223-1230. doi:10.1111/pan.14995
