What is the recommended anesthetic management for a patient with ischemic heart disease (IHD) and an ejection fraction (EF) of 50%?

Anesthetic Management of IHD Patient with EF 50%

For a patient with ischemic heart disease and an ejection fraction of 50% undergoing noncardiac surgery, prioritize hemodynamic stability through careful titration of anesthetic agents, avoidance of rapid bolus dosing, maintenance of coronary perfusion pressure, and continuation of beta-blocker therapy throughout the perioperative period.

Preoperative Optimization

Cardiac Risk Stratification

• Continue all cardiac medications through the morning of surgery, particularly beta-blockers, as abrupt discontinuation increases perioperative cardiac risk 1
• Assess functional capacity: patients with ≥4 METs generally tolerate surgery well without additional testing 1
• For intermediate-risk surgery with 1-2 clinical risk factors and poor functional capacity (<4 METs), noninvasive stress testing may be considered if it will change management 1

Medical Therapy Continuation

• Maintain guideline-directed medical therapy including ACE inhibitors/ARBs and beta-blockers unless hemodynamic instability develops 2
• Beta-blocker therapy should be initiated before and continued during and after the surgical procedure to reduce sympathetic nervous system activity 3
• Ensure euvolemic status before elective procedures, avoiding excessive diuresis which precipitates hypotension 4

Intraoperative Management

Hemodynamic Goals

The primary objectives are maintaining coronary perfusion pressure, controlling heart rate, and avoiding tachycardia and hypotension 3:

• Preserve diastolic blood pressure: decreases in diastolic arterial pressure with severe coronary stenoses reduce myocardial blood flow 3
• Target heart rate control: reduction in heart rate increases oxygen supply and reduces demand; beta-blockers are most effective 3
• Avoid rapid hemodynamic swings: gradual titration prevents myocardial ischemia 3

Anesthetic Agent Selection

Induction Agents

Avoid rapid bolus induction with propofol in patients with cardiac disease, as it causes dose-dependent decreases in preload and afterload 5:

• Use slow titration: approximately 20 mg every 10 seconds until loss of consciousness (0.5-1.5 mg/kg total) 5
• Propofol reduces myocardial oxygen consumption but also decreases blood pressure proportional to blood concentrations achieved 5
• Consider etomidate or reduced-dose propofol for hemodynamically unstable patients

Maintenance Anesthesia

Volatile anesthetics (sevoflurane, isoflurane) are appropriate choices for patients with IHD and preserved EF 6:

• Sevoflurane was equivalent to isoflurane in patients at mild-to-moderate risk for myocardial ischemia undergoing noncardiac surgery, with no significant difference in intraoperative hemodynamics, cardioactive drug use, or ischemic incidents 6
• In CABG surgery patients, sevoflurane (average 0.49 MAC) showed no significant differences in hemodynamics or ischemia incidence compared to isoflurane 6
• Volatile anesthetics decrease myocardial contractility, reducing oxygen demand 3
• May provide myocardial preconditioning against stunning and infarction through adenosine triphosphate-dependent potassium channel stimulation 3

Opioid Supplementation

• Appropriate use of opioids prevents stress response and catecholamine release 3
• Morphine premedication (0.15 mg/kg) with nitrous oxide decreases necessary propofol maintenance infusion rates 5
• When opioid is the primary agent, propofol maintenance rates should not be less than 50 mcg/kg/min, with care to ensure amnesia 5

Intraoperative Monitoring

Standard ASA monitoring plus:

• Continuous 5-lead ECG with ST-segment analysis for ischemia detection
• Invasive arterial blood pressure monitoring for beat-to-beat assessment and rapid intervention
• Consider central venous pressure monitoring if significant fluid shifts expected
• Maintain normothermia to reduce myocardial oxygen demand

Specific Hemodynamic Targets

• Systolic blood pressure: within 20% of baseline to maintain coronary perfusion 3
• Heart rate: 60-80 bpm to optimize diastolic filling time and coronary perfusion 3
• Mean arterial pressure: >65 mmHg to ensure adequate coronary perfusion pressure
• Treat hypotension with phenylephrine or fluid administration rather than reducing anesthetic depth alone 3

Common Pitfalls to Avoid

Critical Errors

• Never use rapid bolus dosing of propofol: causes profound hypotension and decreased coronary perfusion in cardiac patients 5
• Avoid tachycardia at all costs: increases myocardial oxygen demand and reduces diastolic coronary filling time 3
• Do not discontinue beta-blockers perioperatively: increases risk of rebound tachycardia and ischemia 1, 3
• Avoid nondihydropyridine calcium channel blockers if any concern for reduced contractility 1

Medication Considerations

• NSAIDs are contraindicated even with preserved EF, as they promote fluid retention and can precipitate decompensation 7
• Anticholinergic agents should be administered when increases in vagal tone are anticipated during propofol maintenance 5

Postoperative Management

Immediate Recovery

• Continue hemodynamic monitoring in PACU with continuous ECG
• Maintain beta-blocker therapy throughout recovery period 1, 3
• Aggressive pain control to minimize sympathetic surge
• Monitor for signs of myocardial ischemia: chest pain, ST changes, troponin elevation

Risk Stratification Note

While this patient has EF 50% (preserved), the presence of IHD significantly increases perioperative risk regardless of ejection fraction 8. IHD is an important prognostic factor across all HF types and increases risk of cardiovascular events 8.