Heart failure from the anesthesiologist’s point of view

O.O. Pavlov, S.A. Lutsyk


Cardiology patients increasingly become the subject of care by anesthesiologists, both as patients in intensive care and patients in need of pain relief. In this regard, anesthesiologists need to raise the level of knowledge about heart failu­re and clinical aspects that accompany patients during hospital treatment. The modern concept of pharmacotherapy for heart failure is the primary prevention of left ventricular dysfunction. Because hypertension and coronary heart di­sease are major factors of left ventricular dysfunction, ade­quate control of both hypertension (according to the Joint National Committee-7) and hypercholesterolemia was approved as target point of pharmacoprophylaxis. Therapy with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers should be initiated in the presence of diabetes mellitus, stable hypertension or hypercholesterolemia in patients, who are at increased cardiovascular risk despite normal contractile function of the myocardium, in order to avoid complications. In patients with asymptomatic left ventricular dysfunction (ejection fraction ≤ 40 %) (level B), ACE inhibitors and beta-blockers can stop the progression of the disease. In patients with symptomatic heart failure (stage C), the prescription of diuretics helps alleviate symptoms of lung congestion and peripheral edema to recover normal intravascular volume. Administration of ACE inhibitors and beta-blockers is recommended in suspended di­sease progression. Although digoxin has no effect on the survival of patients, its prescription can be justified in stage C, if the patient is tolerant to the administration of ACE inhibitors and diuretics. An alternative for patients with systolic dysfunction and intolerance of ACE inhibitors is isosorbide denigrate combined with hydralazine. The use of nitric oxide donators still remains unresolved issue. In general, the main objectives in the treatment of heart failure include: 1) improving the quality of life, 2) reducing morbidity and 3) reduction in mortality. At this time, the most important way to improve long-term outcome through inhibition of di­sease progression by countering neurohormonal effects. Pharmacological therapy in patients with severe decompensated heart failure (stage D) is based on an assessment of hemodynamic status. Symptomatic treatment with diuretics, vasodilators and inotropic agents supplement the standard scheme of therapy. The results of some clinical trials have shown that continuous therapy with inotropic agents, such as milrinone or inamrinon, led to increased mortality. However, drugs, such as dobutamine and milrinone, have long been used to treat decompensated cardiac output. Thus, today there is controversy about the safety time of using these drugs, for ­example, in patients awaiting heart transplantation. Levosimendan, a cAMP-independent inotropic drug, acts by increasing the sensitivity of myocytes to calcium through stabilization of calcium-mediated structure of troponin C. Levosimendan also opens K+2 channels of vascular smooth muscles, contributing to the expansion of the blood vessels of the heart and protecs against ischemia. Compared with dobutamine, the application of levosimendan decreased the lethality on the first day of the postoperative period and reduced mortality compared to placebo for 14 days after surgery. The sensitivity of myocytes to calcium increased, time of systole increased and the time of diastole did not change preventing calcium overload. This resulted in increased productivity of myocardial contraction and the preserved duration of diastole. The list of approved anesthetic measures and actions in patients requiring anesthesia in the operating room is presented. It is concluded that knowledge of the strategy for pharmacotherapy and correction of heart failure is important in the perioperative period.


heart failure; pharmacotherapy; anesthetic mana­gement


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