Perioperative care of patients with cardiac disease

Patients with cardiovascular disease commonly present with problems requiring surgical treatment. They are more vulnerable than patients without cardiovascular disease to the cardiovascular stresses associated with general anesthesia and surgery--hypotension, hypoxemia, sepsis, and thromboembolism. Their risk of morbidity and mortality is higher. Certain clinical factors have a profound impact on the patient's likelihood of serious cardiac complications or death: Overt heart failure, recent myocardial infarction, and cardiac arrhythmias are the most worrisome. A careful clinical evaluation and formal assessment of the patient's risk dictate better perioperative monitoring and treatment. Early hospital admission provides time for control of other health problems. Prophylaxis with heparin and antimicrobial agents minimizes problems of thromboembolism and sepsis, respectively. Overaggressive treatment of hypertension is avoided, and withdrawal of propranolol or clonidine is carefully supervised. The use of digoxin is restricted to patients with atrial tachyarrhythmias or heart failure. Hemodynamic monitoring via a Swan-Ganz catheter or temporary transvenous pacing may be necessary for selected high-risk patients. Such careful evaluation, monitoring, and treatment are the clinician's methods for improving the chance for patients with heart disease to benefit from surgery.