© 2018 Kurt Pfeifer.

Cardiomyopathy (CHF)

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous cardiovascular disease

  • Previous cardiac testing (stress tests, cardiac catheterization, echocardiography, CT coronary angiography)

  • Previous coronary interventions (including vessel, stent/bypass type)

  • Dry weight

  • Orthopnea/nocturnal dyspnea

  • Chest pain

  • Exertional dyspnea or lightheadedness

  • Palpitations

  • Diaphoresis

  • Fatigue

  • Syncope

Exam

  • S4/S3

  • Pulmonary crackles

  • Edema

  • Elevated JVP

  • Cardiac murmurs

Risk Stratification

No well-validated risk stratification tools​ specific for cardiomyopathy/CHF have been developed. Available studies do indicate that cardiomyopathy/CHF, including HFpEF, confer significant perioperative risk. Risk stratification primarily involves assuring the patient's cardiomyopathy/CHF is fully understood (obtain previous records), stable, and optimally managed.

Diagnostic Studies

  • BMP

  • BNP/NT-proBNP - only if suspected change in status or used for CAD risk stratification (see ischemic cardiac disease assessment section)

  • ECG - within 1-3 months for non-low risk surgery (ACC/AHA guideline)

  • Stress testing - as indicated by ischemic cardiac disease risk assessment

  • ECHOCARDIOGRAM indications (Class of recommendation/level of evidence from ACC/AHA guideline):

    • Dyspnea of unknown origin (​IIa/C) or suspected cardiomyopathy/CHF (author's recommendations)

    • Known CHF with new/progressed symptoms (IIa/C)

    • Stable CHF with no left ventricular function assessment in >1 year (IIb/C) (author would not obtain if patient has good functional capacity and no exam evidence of volume overload)

MANAGEMENT

Indications for Surgical Delay

Medication Management

ACE Inhibitor/ARB Therapy

Beta-Blocker Therapy (ACC/AHA Guideline)

  • Chronic beta-blocker therapy: continue uninterrupted but reasonable to temporarily hold as needed for hypotension/bradycardia​

  • Beta-blocker initiation: unless contraindications are present, patient's with dilated cardiomyopathy/CHF should be on a beta-blocker. However, ACC/AHA guidelines specifically state that "In patients with a compelling long-term indication for beta-blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit."

  • Continue uninterrupted if OK with anesthesiology; if must be held for 24 hours before surgery, restart as soon as possible after surgery

    • CONFLICTING GUIDELINES: ACC/AHA & ESC guidelines both published in 2014. ACC/AHA gave IIa recommendation that continuation uninterrupted is reasonable, but if held before surgery, it is reasonable to resume as soon as possible after (based on evidence that failure to resume ACE inhibitors within 14 days and ARBs within 2 days increases 30-day mortality.) [Mudumbai et al & Lee et al] ESC gave IIa recommendation that continuation uninterrupted is reasonable in stable patients with heart failure, but cessation 24 hours before surgery should be considered for patients taking an ACE inhibitor for HTN. Since then, a substudy of the VISION observational study found a significantly increased risk in stroke, mortality and MINS in patients who took an ACE inhibitor within 24 hours before surgery. [Roshanov et alCCS guidelines published in 2017 recommended withholding ACEi/ARB 24 hours before noncardiac surgery and restarting ACEI/ARB on day 2 after surgery, if the patient is hemodynamically stable. Since the publication of the CCS guidelines, an RCT of holding vs continuing ACEi/ARB was published and showed increased hypotension with continuation but no increase in major adverse outcomes. The study also showed increased severe hypertension from withholding ACEi/ARB. [Shiffermiller et al]

  • Although guidelines do not address neprilysin or renin inhibitors, the author recommends managing these similarly to ACEi/ARB

Other Guideline-Directed Medical Therapy (GDMT)

  • Guidelines also do not comment on perioperative management of nitrates, diuretics, aldosterone antagonists, and ivabradine, but the author recommends continuing these uninterrupted in most patients

Other Perioperative Management

  • Assure euvolemic status with optimal medication management

  • Pursue IV fluid management based on patient's hemodynamics & respiratory status rather than reflexively utilizing a restrictive IV fluid approach for all patients

  • Monitor daily weights and I/Os in inpatient setting

COUNSELING & COMMUNICATION

  • Collaborate with patients' cardiologists

  • Provide anesthesiology with advance notice of patient's with significant cardiomyopathy or LV dysfunction, so appropriate intraoperative care plans can be made

  • Share with patients that current risk estimation tools do not necessarily accurately account for the risks related to cardiomyopathy/CHF, but CHF is clearly associated with increased risk of complications and mortality (Lerman et al)