What are the primary anesthesia recommendations for patients with chronic diastolic heart failure versus chronic systolic heart failure?

Anesthesia Management: Chronic Diastolic vs. Systolic Heart Failure

The fundamental anesthetic difference is that diastolic heart failure requires meticulous maintenance of preload, sinus rhythm, and slower heart rates to preserve diastolic filling time, while systolic heart failure tolerates preload reduction better but requires careful afterload management and contractility support.

Key Pathophysiologic Distinctions

Diastolic Heart Failure (HFpEF)

• Preserved ejection fraction with impaired ventricular relaxation and increased chamber stiffness 1
• The left ventricle is not dilated, and filling pressures are elevated despite normal systolic function 1
• Critically dependent on adequate preload because the stiff ventricle requires higher filling pressures to maintain stroke volume 2
• Atrial contraction contributes up to 40% of ventricular filling, making sinus rhythm preservation essential 2

Systolic Heart Failure (HFrEF)

• Reduced ejection fraction with dilated left ventricle and impaired contractility 1
• Neurohormonal activation is similar to diastolic failure, but the ventricle is volume-overloaded and dilated 1
• More tolerant of preload reduction but highly sensitive to increases in afterload 3

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Preoperative Optimization

For Both Types

• Continue all guideline-directed medical therapy through the morning of surgery, including ACE inhibitors, beta-blockers, and aldosterone antagonists, as these medications reduce perioperative mortality 3, 4
• Verify that beta-blockers are at target doses (metoprolol succinate 200 mg daily, carvedilol 25 mg twice daily, or bisoprolol 10 mg daily) 5, 6
• Patients with LVEF <30% have significantly increased perioperative mortality and myocardial infarction rates 4
• Measure BNP or NT-proBNP for risk stratification, as elevated levels predict adverse perioperative outcomes 4

Diastolic-Specific Considerations

• Ensure euvolemia but avoid excessive diuresis, as over-diuresis precipitates hypotension and reduced cardiac output in the preload-dependent diastolic dysfunction patient 2
• Optimize heart rate control with beta-blockers or rate-limiting calcium channel blockers (verapamil) to maximize diastolic filling time 7, 2
• If atrial fibrillation is present, achieve strict rate control (target heart rate 60-80 bpm) with digoxin as first-line for symptomatic patients 7, 2

Systolic-Specific Considerations

• Optimize volume status with diuretics to reduce pulmonary congestion, but maintain adequate preload 5
• Ensure ACE inhibitor or ARB is continued, as these reduce afterload and improve outcomes 5, 3
• Add spironolactone if LVEF ≤35% and not already prescribed 5, 6

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Intraoperative Anesthetic Management

Hemodynamic Goals: Diastolic Heart Failure

• Maintain heart rate 60-80 bpm to maximize diastolic filling time; tachycardia significantly worsens symptoms by reducing filling time 7, 2
• Preserve sinus rhythm aggressively; treat new-onset atrial fibrillation immediately with cardioversion or rate control, as loss of atrial kick reduces cardiac output by up to 40% 2
• Maintain higher filling pressures (CVP 10-14 mmHg, PCWP 15-18 mmHg) because the stiff ventricle requires elevated preload 2
• Avoid hypotension; maintain MAP >70 mmHg to ensure coronary perfusion during the shortened diastolic period 2
• Avoid excessive fluid administration, but do not allow hypovolemia, as both extremes are poorly tolerated 2

Hemodynamic Goals: Systolic Heart Failure

• Reduce afterload to optimize forward flow from the failing ventricle; maintain SVR in low-normal range 3, 8
• Maintain adequate but not excessive preload (CVP 8-12 mmHg, PCWP 12-15 mmHg) 3
• Support contractility with inotropes only if absolutely necessary (milrinone, levosimendan), as beta-mimetics and PDE-III inhibitors should be reserved for very selected patients with refractory low cardiac output 4
• Maintain heart rate 70-90 bpm; avoid severe bradycardia but also avoid excessive tachycardia that increases myocardial oxygen demand 3

Monitoring

• Invasive arterial blood pressure monitoring is mandatory for both types to detect beat-to-beat hemodynamic changes 8, 4
• Central venous pressure monitoring or pulmonary artery catheterization should be strongly considered for major surgery or hemodynamically unstable patients 8, 4
• Transesophageal echocardiography provides real-time assessment of ventricular filling, contractility, and valvular function 8

Anesthetic Technique Selection

• Neuraxial anesthesia must be used cautiously in diastolic failure due to sympathectomy-induced preload reduction and potential for severe hypotension 2
• For systolic failure, neuraxial techniques may be beneficial by reducing afterload, but titrate slowly to avoid precipitous blood pressure drops 3
• General anesthesia with etomidate or low-dose propofol is preferred for induction to minimize myocardial depression 3, 8
• Avoid high-dose volatile anesthetics that depress contractility; use balanced technique with opioids 3, 8

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Intraoperative Pharmacologic Management

Diastolic Heart Failure

• Beta-blockers (esmolol) for acute heart rate control if tachycardia develops 7, 2
• Phenylephrine for hypotension to maintain preload and coronary perfusion pressure without increasing heart rate 2
• Avoid vasodilators (nitroglycerin, hydralazine) that reduce preload excessively 2
• Calcium channel blockers (diltiazem, verapamil) for rate control in atrial fibrillation 7, 2

Systolic Heart Failure

• Milrinone (0.375-0.75 mcg/kg/min) for inotropic support and afterload reduction if cardiac output is inadequate despite optimization 8, 4
• Vasopressin or norepinephrine for hypotension to maintain perfusion pressure while minimizing increases in SVR 8
• Avoid pure alpha-agonists (phenylephrine) that increase afterload and worsen forward flow 3
• Nitroglycerin for afterload reduction if blood pressure permits 3

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Critical Pitfalls to Avoid

Diastolic Heart Failure

• Excessive diuresis preoperatively or intraoperatively precipitates cardiovascular collapse because the stiff ventricle cannot compensate for reduced preload 2
• Allowing tachycardia >100 bpm severely compromises diastolic filling and can trigger acute pulmonary edema 2
• Loss of atrial contraction (atrial fibrillation) reduces cardiac output by 40%; cardiovert or control rate immediately 2
• Aggressive fluid resuscitation can cause flash pulmonary edema due to the stiff ventricle's inability to accommodate volume 2

Systolic Heart Failure

• Increasing afterload with pure vasoconstrictors worsens forward flow and can precipitate acute decompensation 3
• Routine use of inotropes increases myocardial oxygen demand and arrhythmia risk; reserve for refractory low output states 4
• Discontinuing beta-blockers perioperatively increases mortality risk; continue through surgery 3, 4
• 25% of patients experience acute heart failure exacerbation perioperatively; maintain high index of suspicion 4

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Postoperative Management

For Both Types

• Continue all home heart failure medications immediately postoperatively 3, 4
• Monitor for acute exacerbations, which occur in 25% of heart failure patients perioperatively 4
• Maintain strict fluid balance monitoring with daily weights 5

Diastolic-Specific

• Avoid aggressive diuresis; maintain euvolemia with careful fluid management 2
• Continue beta-blockade or rate-limiting calcium channel blockers for heart rate control 2

Systolic-Specific

• Resume ACE inhibitors/ARBs as soon as hemodynamically stable 5, 3
• Optimize diuretic therapy to relieve congestion while maintaining adequate perfusion 5