What peri‑operative assessment and management should be used for an elderly patient (≥65 years) with diastolic dysfunction (heart failure with preserved ejection fraction) undergoing anesthesia?

Perioperative Management of Diastolic Dysfunction in the Elderly

Elderly patients (≥65 years) with diastolic dysfunction (HFpEF) require meticulous hemodynamic management during anesthesia, with the primary goal of maintaining adequate preload, avoiding hypotension, controlling heart rate, and preventing fluid overload—all while recognizing these patients are exquisitely sensitive to acute changes in loading conditions. 1

Pre-operative Assessment

Mandatory Evaluation Components

Senior assessment by both an experienced anaesthetist and geriatrician is essential for high-risk elderly patients with cardiac comorbidities. 2

Key assessment elements specific to HFpEF include:

• Functional capacity and frailty status using validated tools, as these independently predict perioperative risk beyond cardiac function alone 2
• Cognitive function screening to establish baseline and identify patients at high risk for postoperative delirium 2
• Transthoracic echocardiography with diastolic function assessment to confirm HFpEF diagnosis and quantify severity 2
• Natriuretic peptide levels (NT-proBNP ≥125 ng/L or BNP ≥35 pg/mL) to confirm diagnosis and assess volume status 2
• Comorbidity optimization, particularly hypertension (target <140/90 mmHg, or <130/80 mmHg if high cardiovascular risk), atrial fibrillation, and diabetes 2
• Medication review focusing on rate control agents (beta-blockers or non-dihydropyridine calcium channel blockers) and diuretics 2

Risk Stratification

Emergency surgery in elderly patients carries substantially higher risk than elective procedures, and optimization must occur simultaneously with surgery rather than delaying intervention. 2

Specific risk factors in HFpEF patients include:

• Age >75 years combined with major surgery (>2 hours) significantly increases cardiac complications 3
• Atrial fibrillation, which is common in HFpEF and increases risk of acute decompensation due to loss of atrial contribution to ventricular filling 2, 1
• Reduced physiological reserve making these patients vulnerable to ischemia from even minor hemodynamic perturbations 2, 1

Intraoperative Management

Hemodynamic Goals

The cornerstone of anesthetic management is maintaining adequate preload while avoiding both hypovolemia and fluid overload, as HFpEF patients have steep pressure-volume relationships and tolerate neither extreme. 1

Specific targets:

• Maintain systolic blood pressure within 10% of baseline to ensure adequate coronary and cerebral perfusion 2, 4
• Avoid tachycardia (heart rate >90 bpm), as shortened diastolic filling time precipitates pulmonary congestion in stiff ventricles 2, 1
• Preserve sinus rhythm when possible, as atrial fibrillation with rapid ventricular response can cause acute decompensation 2

Monitoring Strategy

Invasive arterial blood pressure monitoring should be instituted early in elderly unwell patients with HFpEF, as non-invasive methods may be unreliable and beat-to-beat monitoring is essential. 2

Additional monitoring considerations:

• Cardiac output monitoring (esophageal Doppler or other technologies) may be less accurate in elderly patients due to aortic stiffness, potentially overestimating cardiac output and leading to inadequate fluid resuscitation 2
• Cerebral oximetry monitoring with intervention for desaturation >15% (maintain SpO₂ >95%, SBP within 10% baseline) may reduce postoperative delirium and cognitive dysfunction 2
• Depth of anesthesia monitoring (BIS or entropy) is essential, as elderly patients require lower anesthetic doses and inadvertent overdosing causes profound hypotension 2
• Neuromuscular monitoring should be routine, as pharmacokinetic changes cause unpredictably prolonged blockade 2
• Core temperature monitoring (tympanic, pharyngeal, or esophageal) is mandatory for procedures >30 minutes, with target >36°C 4, 3

Fluid Management

Use restrictive fluid therapy that replaces pre-operative and intra-operative losses without causing hypovolemia, administering fluids in small divided boluses (e.g., 100-250 mL) with careful assessment of response after each bolus. 2

Critical principles:

• Avoid prolonged pre-operative fasting—allow clear fluids up to 2 hours before surgery to prevent dehydration 2
• Warm all intravenous fluids, as cold fluids (<21°C) increase hypothermia risk and cardiac arrest (48% vs 12% with warmed fluids) 3
• Monitor for fluid overload continuously, as HFpEF patients rapidly develop pulmonary congestion with modest volume excess 1

Anesthetic Technique Selection

Regional anesthesia is preferable when feasible, but requires meticulous attention to preventing hypotension from sympathetic blockade. 1

For general anesthesia:

• Reduce induction agent doses by 30-50% based on age-adjusted algorithms, as elderly patients are exquisitely sensitive to hypotension from anesthetic overdose 2
• Use depth-of-anesthesia monitoring or Lerou nomograms for age-adjusted MAC values if monitors unavailable 2
• Avoid the "triple low" (low BIS, hypotension, low volatile agent concentration), which is associated with increased mortality 2

For neuraxial anesthesia:

• Anticipate and prevent hypotension from sympathetic blockade, which causes rapid core-to-peripheral heat redistribution (0.5-1.5°C drop in 30-60 minutes) and impairs compensatory vasoconstriction 3
• Administer fluids cautiously before spinal/epidural, as aggressive preloading can precipitate pulmonary edema in stiff ventricles 1

Rate Control in Atrial Fibrillation

For HFpEF patients in atrial fibrillation, control resting heart rate using beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil). 2

Acute management:

• Intravenous beta-blockers or non-dihydropyridine calcium channel blockers are recommended for acute rate control, with caution in patients with overt congestion or hypotension 2
• Intravenous digoxin or amiodarone are alternatives for rate control in hemodynamically unstable patients 2
• Do NOT use IV calcium channel blockers, IV beta-blockers, or dronedarone in decompensated heart failure 2

Temperature Management

Begin active warming pre-operatively and continue throughout the perioperative period using forced-air warming devices combined with warmed IV fluids, as elderly patients lose heat rapidly and have difficulty rewarming. 4, 3

Specific interventions:

• Measure baseline tympanic temperature and document it pre-operatively 4
• Apply forced-air warming in the pre-operative holding area to prevent redistribution hypothermia after anesthetic induction 4
• Continue active warming during transport to and from operating theaters and in recovery, as these are high-risk periods for heat loss 4
• Target core temperature >36°C, as hypothermia causes postoperative delirium, cardiac dysfunction, myocardial ischemia (6.3% vs 1.4%), and prolonged hospital stay 4, 3

Postoperative Management

Immediate Recovery Period

Continue invasive monitoring and active warming in the recovery area, with particular attention to preventing hypotension, maintaining adequate oxygenation, and detecting early signs of decompensation. 4, 5

Key interventions:

• Serial ECGs (baseline, immediately post-op, daily for 2 days) to detect myocardial ischemia, which is a strong predictor of perioperative MI in high-risk patients 5
• Cardiac biomarkers (troponin or CK-MB) if ECG changes or hemodynamic instability develop, recognizing that perioperative MI carries 40-70% mortality 5
• Echocardiography for unexplained hemodynamic instability to assess ventricular function and volume status 5

Delirium Prevention

Implement multimodal interventions to prevent postoperative delirium, which is directly caused by hypothermia, hypotension, and cerebral ischemia in elderly patients. 2, 4

Risk factors requiring heightened vigilance:

• Very old age (>75 years), frailty, pre-existing cognitive impairment, cerebrovascular disease, and multimorbidity all increase delirium risk 2
• Early recognition and communication throughout the multidisciplinary team facilitates preventive interventions 2

Management of Complications

If hemodynamic instability develops:

• First assess volume status using dynamic hemodynamic parameters and echocardiography 5
• For myocardial dysfunction, use low-to-moderate doses of dobutamine/epinephrine, milrinone, or levosimendan 5
• For hypotension with adequate volume, use norepinephrine to maintain perfusion pressure 5
• For refractory cardiogenic shock, consider intra-aortic balloon pump before end-organ dysfunction develops 5

Common Pitfalls to Avoid

• Do not assume normal ejection fraction means normal cardiac function—HFpEF patients have profound diastolic dysfunction and reduced reserve 1, 6
• Do not use standard fluid boluses (500-1000 mL)—give smaller aliquots (100-250 mL) and reassess frequently 2, 1
• Do not allow tachycardia to persist—shortened diastolic filling time rapidly causes pulmonary congestion in stiff ventricles 2, 1
• Do not delay invasive monitoring—elderly HFpEF patients decompensate rapidly and require beat-to-beat blood pressure assessment 2
• Do not treat hypothermia reactively—implement active warming prophylactically from the pre-operative period 4, 3
• Do not use standard anesthetic doses—reduce by 30-50% based on age-adjusted algorithms to prevent profound hypotension 2