Issues in the perioperative management of the elderly patient with cardiovascular disease

The elderly patient may show normal physiological changes of the cardiovascular and respiratory systems that accompany aging, as well as features of intrinsic cardiac disease. The latter include: a past history of myocardial infarction or ischaemic heart disease; history of congestive cardiac failure; angina; arterial hypertension (BP >140/90mm Hg); and conduction disorders. A key aspect to the safe and effective anaesthetic management of the elderly patient with cardiac disease is a careful preoperative assessment and optimisation of pre-existing drug therapies. All cardiac medications should be continued up to and including the morning of surgery with the exception of anticoagulation involving warfarin, and perhaps large doses of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists in patients with hypertension or heart failure. Anaesthetic techniques used in these patients should avoid episodes of excessive hypotension after induction of anaesthesia or large blood loss, or the combination of hypertension and tachycardia after noxious stimulation. The latter physiological disturbances are pivotal for the development of myocardial ischaemia. Both premedication (if used) and anaesthesia should avoid excessive sedation and respiratory depression. The choice of anaesthetic technique may vary between: a balanced technique involving an opiate and a volatile agent; an intravenous technique utilising infusions of propofol; or regional anaesthesia with or without additional sedation. There are no good data to suggest any one technique is better than the rest. The occurrence of ischaemia in the perioperative period may precede the postoperative development of significant cardiac morbidity and mortality (including myocardial infarction or unstable angina, congestive cardiac failure, cerebrovascular accidents, and severe arrhythmias). A number of strategies have been examined to reduce these adverse outcomes. The effect of acute beta-adrenoceptor blockade in treatment-naive patients is associated with reduction in the haemodynamic response to noxious stimuli and decreased ECG evidence of myocardial ischaemia, as well as a reduction in the number of cardiac adverse events. Other drugs (calcium channel antagonists, alpha(2)-agonists and adenosine modulators) have a less predictable influence on both myocardial ischaemia and hard cardiac outcomes. There is inadequate evidence at present to define the optimal time course for acute beta-blockade, or the groups of patients in whom preoperative beta-blockade should be initiated in the absence of contraindications. Nevertheless, addition of beta-blockers to the preoperative regimen should be considered in patients with evidence of or at risk for coronary disease undergoing major surgery. There is also evidence that long-term beta-adrenoceptor or calcium channel blockade or nitrate therapy for the high-risk cardiac patient offers little protection against silent myocardial ischaemia, nonfatal infarction, cardiac failure and cardiac death.