Sammendrag
The anaesthesiologist should take a strong part in the perioperative care of patients with cardiac disease. The interaction between the different specialists may determine the outcome of the procedure. A system for mediating perioperative communication on patients should be in place. Such a system should ensure the smooth preparation of cardiac patients and prevent the delay of surgery. The knowledge of the anaesthesio¬logist is important for risk assessment and for the optimal preparation before surgery. Skills and knowledge of physiology and patho-physiology are vital for the intra-operative management and also for the postoperative follow-up, including pain control, cardio-respiratory management, fluid therapy, and nutrition. Most patients with cardiac disease should gain from the optimization of preoperative organ dysfunction (Slogoff & Keats 1985, Sprung 2000).
Unfortunately, there is a lack of strong evidence-based data supporting the choice for a particular perioperative approach. Several options are therefore available. Many studies and randomized trials have been performed often on a limited number of patients. Despite that they have addressed the potential relation between anaesthetic management and patient outcome, sufficiently powered randomized trials showing the advantage of a specific perioperative approach are still lacking. In particular, the outcome of cardiac patients after non-cardiac surgery has not been fully addressed.
Cardiac failure is manifested through dyspnoea, peripheral oedema, liver enlargement and signs of pulmonary congestion. Patients in cardiac failure tend to have elevated levels of N-terminal pro- brain natriuretic peptide (NT-BNP). Increased levels of NT-BNP correlate with increased risk of death. Recent studies of large cohorts have shown a significant higher mortality in patients coming for non-cardiac surgery if they have had the diagnosis of cardiac failure the year before surgery. The mortality was also higher in patients with coronary artery disease but the outcome was much closer to the outcome of patient without these two diagnoses (Hernanez 2004, Hammil 2008).
A normal reaction to stress testing can predict a high chance for event-free perioperative course. One of the debatable issues in recent years has been whether the patient with coronary heart disease should have the non-cardiac surgery delayed and undergo coronary interventions. Acute coronary syndromes and unstable angina pectoris are high risk situations. Acute interventions are recommended in these cases or - if possible - the delay of non-cardiac surgery. However, there is scarce evidence for improved outcome with interventions in stable patients. Despite the lack of sufficient hard evidence, it seems reasonable to optimize overt heart failure and optimize medical treatment of ischaemic heart disease before non-cardiac surgery.
Perioperative beta blockade has been used for more than 30 years in anaesthesia. The use of perioperative beta-blocker was increased after the papers by Mangano at al (1996) and Poldermans et al (1999). Later other papers were less optimistic and this year’s publication of the POISE study have rendered a cautious attitude among the experts (Juel et al 2006, POISE 2008). The value of preoperative echocardiography in non-symptomatic patients before non-cardiac surgery has been set under debate. Patients enrolled in the POISE study could have had non-symptomatic heart failure contributing to the negative effects from rapid and high dose of beta-blockers in the protocol. The ACE inhibitors or AII blockers should probably be stopped the day before surgery whether the indication be heart failure or hypertension.
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