Anesthetic Considerations for Patients with Heart Disease

Cardiovascular disease, which is the leading cause of death for both men and women in the United States,1 refers to various types of heart conditions that affect health and mortality. These conditions include coronary artery disease, cerebrovascular disease (stroke), congenital cardiovascular defects, heart rhythms, sudden cardiac arrest, cardiomyopathy, heart failure and more.2 According to the Centers for Disease Control and Prevention (CDC), having an unhealthy diet, sedentary lifestyle, high cholesterol, high blood pressure or diabetes can increase one’s risk of heart disease, as can smoking tobacco.3 Additionally, 0.4 to 1 per 100 United States infants are born with congenital heart disease, ranging from mild asymptomatic lesions to fatal conditions.2 Given the ubiquity of heart disease, medical providers must consider the complexity of a patient with cardiovascular issues. Anesthesiology practitioners, for example, need to account for cardiovascular disease before, during and after surgery to avoid complications or even mortality. 

Risks associated with anesthesia for patients with cardiovascular disease are common in children as well as adults. Ramamoorthy et al. used data from the Pediatric Perioperative Cardiac Arrest Registry to analyze 373 anesthesia-related cardiac arrests in children, 34 percent of whom had congenital or acquired heart disease.4 The authors found that children with heart disease were sicker than those without heart disease at the time of cardiac arrest and had a higher mortality rate.4 Though most of these events occurred during surgery, another study found that children with congenital heart disease could go into cardiac arrest throughout the perioperative period.5 In their paper, Cannesson et al. stress the risk of stroke, thrombosis (blood clots), heart failure and dysrhythmia during surgery for adults with congenital heart disease,6 while Odegard et al. emphasize cardiac arrest in similar patients.7 For children and adults with heart disease, the risks of cardiovascular or cerebrovascular complications in surgery are high. 

Given these risks, the anesthesiologist should adequately prepare the patient for surgery. Because preoperative fasting may increase risk of cerebrovascular thrombosis, the anesthesia provider should preoperatively assess the patient’s coagulation system and consistently hydrate the patient with intravenous fluids.6 The anesthesiologist may also have to premedicate the patient with anxiolytics and hypnotics in order to prepare the cardiovascular patient for a stressful surgery.6 For patients with congenital heart defects, the anesthesiologist must become familiar with the patient’s unique physiology in order to adequately prepare for a procedure.8 Some hospitals may apply strict guidelines for care or use technology, such as computer algorithms, to assess anesthesia-related risks in children with congenital heart disease.5 Preoperative preparation of patients with cardiovascular disease, such as adequate hydration and analysis of the patient’s particular condition, are necessary roles of the anesthesia provider. 

During surgery, the anesthesia practitioner is responsible for collaborating with other health professionals to ensure a seamless procedure.8 This includes vigilantly monitoring the patient to maintain steady blood pressure throughout and after the procedure.9 In children with congenital heart disease, anesthesia-related cardiac arrests occur most commonly during the procedure (as opposed to before or after), so anesthesia providers should constantly be aware of a patient’s vital signs.4 Also, using the right type of medication and anesthesia for a specific cardiovascular disease is essential to preventing complications or mortality. Studies suggest using diazepam,10 midazolam11 and/or a combination of epidural anesthesia and light general anesthesia12 to provide rapid, stable induction of anesthesia in patients with heart disease. Meanwhile, Russell et al. found that sevoflurane may have advantages over halothane in maintaining hemodynamic stability for children with congenital heart disease.13 

Risk of complications during surgery are high for patients with congenital or acquired heart disease. Given the possibility of anesthesia-related cardiac arrest or stroke, anesthesia providers must assess and monitor patients throughout the perioperative period. Before a procedure, the anesthesia practitioner should evaluate the patient’s anatomy and particularities of the heart disease, and provide treatments such as hydration and premedication. During surgery, provision of an appropriate anesthetic agent and collaboration with other professionals in the procedure room are important duties of the anesthesiologist. Furthermore, consistent vital signs monitoring is crucial during and after surgery. 

1. Centers for Disease Control and Prevention. Heart Disease in the United States. Heart Disease Facts 2019;

2. Benjamin EJ, Virani SS, Callaway CW, et al. Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association. Circulation. 2018;137(12):e67–e492. 

3. National Center for Chronic Disease Prevention and Health Promotion. Know the Facts About Heart Disease. Atlanta, GA: Centers for Disease Control and Prevention;2019. 

4. Ramamoorthy C, Haberkern CM, Bhananker SM, et al. Anesthesia-Related Cardiac Arrest in Children with Heart Disease: Data from the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesia & Analgesia. 2010;110(5):1376–1382. 

5. Taylor D, Habre W. Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease. Pediatric Anesthesia. 2019;29(5):426–434. 

6. Cannesson M, M.D., Earing Michael G, M.D., Collange V, M.D., Kersten Judy R, M.D., F.A.C.C. Anesthesia for Noncardiac Surgery in Adults with Congenital Heart Disease. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2009;111(2):432–440. 

7. Odegard KC, DiNardo JA, Kussman BD, et al. The Frequency of Anesthesia-Related Cardiac Arrests in Patients with Congenital Heart Disease Undergoing Cardiac Surgery. Anesthesia & Analgesia. 2007;105(2):335–343. 

8. Gottlieb EA, Andropoulos DB. Anesthesia for the patient with congenital heart disease presenting for noncardiac surgery. Current Opinion in Anesthesiology. 2013;26(3):318–326. 

9. Howell SJ, Sear JW, Foëx P. Hypertension, hypertensive heart disease and perioperative cardiac risk. BJA: British Journal of Anaesthesia. 2004;92(4):570–583. 

10. Samuelson PN, Reves JG, Kouchoukos NT, Smith LR, Dole KM. Hemodynamic responses to anesthetic induction with midazolam or diazepam in patients with ischemic heart disease. Anesthesia and Analgesia. 1981;60(11):802–809. 

11. Middlehurst RJ, Gibbs A, Walton G. Cardiovascular risk: The safety of local anesthesia, vasoconstrictors, and sedation in heart disease. Anesthesia Progress. 1999;46(4):118–123. 

12. Reiz S, Bålfors E, Sørensen MB, Häggmark S, Nyhman H. Coronary Hemodynamic Effects of General Anesthesia and Surgery: Modification by Epidural Analgesia in Patients with Ischemic Heart Disease. Regional Anesthesia: The Journal of Neural Blockade in Obstetrics, Surgery, & Pain Control. 1982;7(Suppl 4):S8–S18. 

13. Russell IA, Miller Hance WC, Gregory G, et al. The Safety and Efficacy of Sevoflurane Anesthesia in Infants and Children with Congenital Heart Disease. Anesthesia & Analgesia. 2001;92(5):1152–1158.