Management of Cardiovascular Abnormalities in Perioperative Adult-Gerontology Patients

Risk Assessment and Stratification

The American College of Cardiology recommends a thorough preoperative assessment, including systemic arterial oximetry, ECG, chest x-ray, transthoracic echocardiography, complete blood count, and coagulation screening, for adult-gerontology patients with perioperative risk factors 1
Major perioperative risk indicators include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and valvular disease, according to the American Heart Association 2
Clinical risk factors include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, and high-risk surgery, as identified by the American College of Cardiology 2
For patients with known or suspected coronary artery disease, the American College of Cardiology recommends a stepwise approach to risk assessment, including tools like the Revised Cardiac Risk Index or American College of Surgeons NSQIP risk calculator 3, 4

Certain patient populations, such as those with prior Fontan procedure, severe pulmonary arterial hypertension, cyanotic congenital heart disease, complex congenital heart disease, or left ventricular assist devices, should be managed at specialized centers for adult congenital heart disease or cardiovascular care, as recommended by the American Heart Association 1, 5, 6

The American College of Cardiology recommends obtaining ECGs at baseline, immediately after surgery, and on the first two postoperative days for patients with cardiovascular abnormalities undergoing high-risk procedures 7, 8
Monitoring cardiac biomarkers is recommended in high-risk patients and those with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction, according to the American Heart Association 7, 8
Assessing heart function using echocardiography and pulmonary artery catheterization is recommended, especially in patients with right heart dysfunction, as suggested by the American College of Cardiology 2, 9

For myocardial dysfunction, the American College of Cardiology recommends considering low-to-moderate doses of dobutamine and epinephrine, milrinone, or levosimendan, either alone or in combination 2, 9
For vasoplegia-induced hypotension, the American Heart Association recommends using norepinephrine to maintain adequate perfusion pressure 2, 9
For patients experiencing perioperative ST-segment elevation MI, the American College of Cardiology recommends considering aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors 7, 8

Adult congenital heart disease patients should be risk-stratified based on anatomy and complexity of their condition, as recommended by the American Heart Association 6
For cyanotic patients, bleeding risk can be reduced by preoperative phlebotomy if hematocrit exceeds 65%, according to the American College of Cardiology 5

In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended, as suggested by the American College of Cardiology 2, 9
Consideration of ventricular assist devices is recommended before end-organ dysfunction becomes evident, according to the American Heart Association 2, 9

Perioperative MI carries a 40-70% mortality rate and high risk for future cardiac events, as reported by the American College of Cardiology 7, 8
Long operations with hemodynamic instability requiring large-volume fluid replacement are associated with increased perioperative mortality in patients with congenital heart disease, according to the American Heart Association 5

Clinical risk factors that increase perioperative cardiovascular risk include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, and high-risk surgery, as noted by the American College of Cardiology 10

B-type natriuretic peptide level before surgery serves as an additional risk stratification factor, according to the American College of Cardiology 10

The distinction between cardiogenic shock and transient postoperative cardiac stunning is important as they are associated with different hospital paths and outcomes, as reported in Critical Care 10

Postoperative cardiovascular dysfunction may be characterized by unexpectedly low systemic vascular resistance (vasodilatory shock), which requires specific management approaches, as noted in Critical Care 10