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# The patient with heart disease having non-cardiac surgery

- Patient and surgery

A weak or narrowed heart copes badly with the stress of surgery, so the anaesthetist plans to keep its supply and demand of oxygen in balance.

Updated Nov 13, 2026

## Key points

- In ischaemic heart disease the enemy is tachycardia: it raises oxygen demand and shortens diastole, when the left ventricle is perfused.
- Aortic stenosis: keep sinus rhythm, a normal-to-slow rate, preload and systemic vascular resistance; sudden vasodilation can cause cardiac arrest.
- Pulmonary hypertension: avoid hypoxaemia, hypercapnia, acidosis, hypothermia and pain, and keep systemic pressure up to perfuse the right ventricle.
- Continue beta-blockers and statins; do not stop antiplatelets after a recent coronary stent without the cardiologist.
- Pacemakers and defibrillators need a plan: anti-tachycardia therapy suspended for diathermy, and the device rechecked after surgery.

On this page

- The basics Key points
- What it is
- What changes in this patient
- Anaesthetic plan (and why)
- Haemodynamic goals by lesion, in principle
- Next step
- Memory aid
- Elsewhere in DurgiPedia

- Clinical Risks and complications

- Study Test yourself

- Connections Connections

## What it is

Patients with ischaemic heart disease, heart failure, valve disease, pulmonary hypertension, arrhythmias or cardiac devices face a higher risk of myocardial injury, infarction, heart failure, arrhythmia and death around non-cardiac surgery. Surgery and anaesthesia stress the heart through pain, catecholamine release, fluid shifts, bleeding, hypothermia and the vasodilating and depressant effects of the anaesthetic itself. The anaesthetic plan rests on physiology rather than on any single 'best' technique: in ischaemic disease it keeps myocardial oxygen supply above demand by avoiding tachycardia, hypotension, severe hypertension, anaemia, hypoxaemia and shivering; in each valve lesion it keeps the heart rate, preload and afterload that the lesion tolerates; in pulmonary hypertension it avoids everything that raises pulmonary vascular resistance and protects the right ventricle by keeping systemic pressure up. General and regional anaesthesia can both be safe; what matters is a slow, titrated induction, invasive monitoring when the reserve is poor, attention to chronic medicines (beta-blockers and statins continued, antiplatelets after stents discussed with cardiology), a plan for pacemakers and defibrillators, and monitored recovery with a low threshold to look for silent myocardial injury.

## What changes in this patient

- Less reserve: a heart with ischaemia, poor ventricular function or a tight valve cannot raise its output to meet surgical stress.
- Coronary flow to the left ventricle happens mostly in diastole, so a fast heart rate cuts supply while it raises demand.
- Stenotic valves need a slow rate and adequate filling; regurgitant valves tolerate a normal-to-fast rate and dislike a high afterload.
- The right ventricle in pulmonary hypertension is thick, pressure-loaded and fails when pulmonary resistance rises or systemic pressure falls.
- Chronic medicines matter: beta-blockers, statins, ACE inhibitors, antiplatelets and anticoagulants each need a decision before surgery.
- Recent infarction, recent stent, decompensated heart failure and severe symptomatic valve disease make elective surgery wait.

## Anaesthetic plan (and why)

- Confirm the cardiac state and any active condition — elective surgery waits for an acute coronary syndrome or decompensated failure to be treated.
- Plan the chronic medicines with the team — beta-blockers and statins continue; antiplatelets after a stent are stopped only with cardiology.
- Choose general, regional or combined anaesthesia on the patient's lesion — both can be safe if the haemodynamics are controlled.
- Place an arterial line before induction when reserve is poor — beat-to-beat pressure shows a fall at once and guides treatment.
- Induce slowly and titrate the drugs — a smooth induction avoids both deep hypotension and the tachycardia of laryngoscopy.
- Treat hypotension early with a vasopressor matched to the heart rate — coronary and right-ventricular perfusion depend on pressure.
- Prefer gradual onset for neuraxial block in fixed-output lesions — a sudden sympathetic block can drop pressure faster than the heart can respond.
- Keep the patient warm, well oxygenated and not anaemic, and give good analgesia — shivering, hypoxaemia and pain all raise cardiac demand.
- In pulmonary hypertension avoid hypoxaemia, hypercapnia and acidosis, and consider a pulmonary vasodilator — these keep pulmonary resistance low.
- Arrange monitored recovery and check troponin in high-risk patients — myocardial injury after surgery is often silent.

## Haemodynamic goals by lesion, in principle

| Lesion | Heart rate | Preload | Afterload | Avoid |
| --- | --- | --- | --- | --- |
| Ischaemic heart disease | Normal to slow | Normal | Normal | Tachycardia, hypotension, anaemia, shivering |
| Aortic stenosis | Normal to slow, sinus rhythm | Full | Keep it up | Sudden vasodilation, tachycardia, atrial fibrillation |
| Mitral stenosis | Slow | Full but careful | Normal | Tachycardia, fluid overload, high pulmonary pressure |
| Aortic or mitral regurgitation | Normal to slightly fast | Full | Lower | Bradycardia, sharp rises in afterload |
| Pulmonary hypertension | Normal, sinus rhythm | Careful | Systemic up, pulmonary down | Hypoxaemia, hypercapnia, acidosis, pain, hypothermia |

## Risks and complications

- Perioperative myocardial injury or infarction, often without chest pain and found only by troponin.
- Acute heart failure and pulmonary oedema from fluid overload or loss of atrial contraction.
- Profound hypotension and arrest with sudden vasodilation in aortic stenosis or hypertrophic obstructive cardiomyopathy.
- Right ventricular failure in pulmonary hypertension: a spiral of falling pressure, right ventricular ischaemia and lower output.
- New atrial fibrillation or other arrhythmias, and stent thrombosis when antiplatelets are stopped too early.
- Device problems: diathermy interference, inappropriate shocks or a pacemaker left in an unsafe mode.

## Next step

- Postpone elective surgery and refer to cardiology for any active cardiac condition or a recent coronary stent.
- Call a senior anaesthetist early for severe aortic stenosis, pulmonary hypertension, poor ventricular function or an implanted defibrillator.
- Arrange a monitored bed and troponin surveillance for high-risk patients, and treat any myocardial injury found.
- Restart chronic cardiac medicines and anticoagulants after surgery on a written plan agreed with the surgeon.
- Have the pacemaker or defibrillator checked and reactivated before the patient leaves monitored care.

## Memory aid

Stenosis: slow and full. Regurgitation: fast, full and forward (low afterload). Ischaemia: slow, normal pressure, no shivering.

## Test yourself

Think of the answer, then tap the question to see it.

## Why is tachycardia especially harmful in a patient with ischaemic heart disease?

It raises myocardial oxygen demand and shortens diastole, the phase in which the left ventricle receives most of its coronary flow, so supply falls as demand rises.

## What are the haemodynamic goals in severe aortic stenosis?

Sinus rhythm, a normal-to-slow heart rate, adequate preload and a maintained systemic vascular resistance; sudden vasodilation can cause collapse.

## Which factors raise pulmonary vascular resistance and should be avoided in pulmonary hypertension?

Hypoxaemia, hypercapnia, acidosis, hypothermia, pain and light anaesthesia; systemic pressure is kept up to perfuse the right ventricle.

## What should happen to a defibrillator's anti-tachycardia function during surgery with diathermy?

It is usually suspended under monitoring with external pads available, and the device is checked and reactivated after surgery.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/the-patient-with-heart-disease-having-non-cardiac-surgery/)

## Elsewhere in DurgiPedia

- [Coronary circulation and myocardial ischemia](https://durgical.com/en/physiology/coronary-circulation-and-myocardial-ischemia/)
- [The ventricular pressure–volume loop](https://durgical.com/en/physiology/the-ventricular-pressure-volume-loop/)
- [The pulmonary circulation and hypoxic vasoconstriction](https://durgical.com/en/physiology/the-pulmonary-circulation-and-hypoxic-vasoconstriction/)
- [Echocardiography: transthoracic and transoesophageal](https://durgical.com/en/clinical-skills/echocardiography-transthoracic-and-transoesophageal/)
- [Heart failure syndrome: left- and right-sided signs](https://durgical.com/en/clinical-exam/heart-failure-syndrome-left-and-right-sided-signs/)

## Connections

## Related 8

- [Cardiac risk before non-cardiac surgery](https://durgical.com/en/anaesthesia/cardiac-risk-before-non-cardiac-surgery/)
- [Which medicines to continue or stop before surgery](https://durgical.com/en/anaesthesia/which-medicines-to-continue-or-stop-before-surgery/)
- [Anticoagulants, antiplatelets and neuraxial blocks](https://durgical.com/en/anaesthesia/anticoagulants-antiplatelets-and-neuraxial-blocks/)
- [Intraoperative hypotension](https://durgical.com/en/anaesthesia/intraoperative-hypotension/)
- [Haemodynamic monitoring: arterial line, CVP, cardiac output and lactate](https://durgical.com/en/anaesthesia/haemodynamic-monitoring-arterial-line-cvp-cardiac-output-and-lactate/)
- [Vasopressors and inotropes by receptor and mechanism](https://durgical.com/en/anaesthesia/vasopressors-and-inotropes-by-receptor-and-mechanism/)
- [Spinal anaesthesia](https://durgical.com/en/anaesthesia/spinal-anaesthesia/)
- [Anaesthesia for cardiac surgery, in principle](https://durgical.com/en/anaesthesia/anaesthesia-for-cardiac-surgery-in-principle/)

## Related conditions 8

- [Stable angina](https://durgical.com/en/conditions/stable-angina/)
- [Myocardial Infarction (Heart Attack)](https://durgical.com/en/conditions/myocardial-infarction/)
- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/)
- [Mitral stenosis](https://durgical.com/en/conditions/mitral-stenosis/)
- [Pulmonary hypertension and cor pulmonale](https://durgical.com/en/conditions/pulmonary-hypertension-and-cor-pulmonale/)
- [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/)
- [Hypertrophic cardiomyopathy](https://durgical.com/en/conditions/hypertrophic-cardiomyopathy/)

## In Pharmacology 9

- [Beta blockers](https://durgical.com/en/pharmacology/classes/beta-blockers/)
- [Statins](https://durgical.com/en/pharmacology/classes/statins/)
- [ACE inhibitors](https://durgical.com/en/pharmacology/classes/ace-inhibitors/)
- [Angiotensin II receptor blockers (ARBs)](https://durgical.com/en/pharmacology/classes/angiotensin-ii-receptor-blockers/)
- [Antiplatelet drugs](https://durgical.com/en/pharmacology/classes/antiplatelet-drugs/)
- [Direct oral anticoagulants (DOACs)](https://durgical.com/en/pharmacology/classes/direct-oral-anticoagulants/)
- [Phenylephrine](https://durgical.com/en/pharmacology/phenylephrine/)
- [Norepinephrine](https://durgical.com/en/pharmacology/norepinephrine/)
- [Nitric oxide (inhaled)](https://durgical.com/en/pharmacology/nitric-oxide/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Perioperative Cardiac Management](https://www.ncbi.nlm.nih.gov/books/NBK493196/) (StatPearls (NCBI Bookshelf), 2023); [Anesthesia for Patients With Pulmonary Hypertension or Right Heart Failure](https://www.ncbi.nlm.nih.gov/books/NBK572071/) (StatPearls (NCBI Bookshelf), 2025).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/anaesthesia/the-patient-with-heart-disease-having-non-cardiac-surgery/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/the-patient-with-heart-disease-having-non-cardiac-surgery/