The Heart of the Matter:

Anesthesia for Patients with

Cardiac Disease
Molly Shepard DVM Dipl. ACVA
Continuing Education Seminar
Cobb Emergency Veterinary Clinic
October 3rd, 2012
Overview
Cardiac function review
Cardiovascular effects of anesthetic
drugs
Cardiac diseases
General anesthetic considerations
Case examples
Normal cardiac function
It all starts with an action potential
Pacemaker cells

http://php.med.unsw.edu.au/embryolo
gy/index.php?title=Advanced_-
_Cardiac_Conduction
SA node 70-160 bpm
AV node/ His Bundle region
40-60 bpm
Bundle branches/
Purkinje network
20-40 bpm
Action potential pacemaker cell
Craven 2006
Variable cardiac action potentials

http://healthyheart-sundar.blogspot.com/2011/03/cardiac-action-potential.html
Action potentials and ECG
http://www.pharmacolog
y2000.com/Cardio/antiar
r/antiarrtable.htm
Ventricular
muscle
Purkinje fibers
AV node
SA node
Atrial depolarization
http://www.sciencephoto.co
m/media/304266/view
AV node conduction
http://www.sciencephoto.co
m/media/304266/view
Bundle of His, bundle branches
http://www.sciencephoto.co
m/media/304266/view
Purkinje fibers
http://www.sciencephoto.co
m/media/304266/view
Ventricular depolarization
http://www.sciencephoto.co
m/media/304266/view
Ventricular repolarization
http://www.sciencephoto.co
m/media/304266/view
Two full cardiac cycles

http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v02/020536r00.HTM
Evaluation of cardiac function
Physical exam/monitoring
Thoracic auscultation
Heart rate and rhythm
Presence of murmurs
Mucous membrane color
Intestinal color
CRT
Pulse palpation
Pulse quality
Pulse deficits

Evaluation of cardiac function
Heart rate
Heart rhythm
Blood pressure
Indirect
Direct
Pulse oximetry
Capnography
Central venous
pressure
Pressure volume relationships
Cardiac output = Heart Rate x Stroke Volume
Preload
Afterload
Contractility
Determinants of stroke volume

http://www.cvphysiology.co
m/Cardiac%20Function/CF
002.htm
Overview
Cardiac function review
Cardiovascular effects of anesthetic
drugs
Cardiac diseases
General anesthetic considerations
Case examples
Opioids
Minimal CV effects (clinical analgesic
dosing)
Bradycardia
Medullary vagal stimulation
Responds to anticholinergics
Histamine release hypotension
Especially morphine (avoid rapid IV)
http://www.dailymedplus.com/monograph/view/setid/b325028e-0722-4c8c-9fdb-ab6fb0dc460c
Benzodiazepines
Limited CV effects
No appreciable change in HR, myocardial
contractility, CO, ABP
0.5-2.5mg/kg IV (dogs)
Generally cardio-protective
http://vurtpunk.deviantart.com/art/Mr-
Diazepam-13629111
Phenothiazines (acepromazine)
Conscious dogs
Decreases SV, CO, MAP (20-25%, 0.1mg/kg IV)
Increase or no change in HR
Dogs on inhalant
Ace premed then
isoflurane: 24% decrease
in MAP (0.1mg/kg IM)
Conscious cats
30% decrease in MAP
(0.1mg/kg IM)
http://www.gopetplan.com/blogpost/petplan-pet-insurance-presents-a-
sedentary-life--pets-and-anesthesia
Alpha-2-agonists (dexmedetomidine)
Dose-dependent CV effects
Endogenous catecholamines antagonize
the clinical effect
Vasoconstriction hypertension
Reflex bradycardia (e.g. HR<40-50 bpm)
HR and CI decrease (60%, 5-20 micr
domitor/kg, conscious dogs)
Hypertension exacerbated by atropine
when given simultaneously (Congdon 2011)
Dexmedetomidine
~35-45 minutes post injection
Decreased vascular tone hypotension &
decreased cardiac output
CV effects lessened under inhalant

Imidazole hypnotics
(etomidate)
Metomidate in 35% propylene glycol
Can cause hemolysis (clin signif??)
No change in HR, BP or myocardial
performance (canine)
Anti-convulsant properties
May be neuroprotective after global
ischemia (e.g. cardiac arrest)
Should not be used as CRI
Cortisol suppression

http://www.safestchina.
com/wholesalers-
powder-injection/
Dissociatives (ketamine, tiletamine)
Increased sympathetic efferent
activity
Positive inotropy
Increased myocardial O2 demand
2 minutes post injection
Increased HR, MAP, CO
15 min post-inj: normal HR, MAP, CO
No change in vascular tone
http://www.adammaxwell.com/t
he-library/published-
online/special-k-and-the-
yorkshire-terrier-floatation/
Sedative hypnotic (propofol)
Decreases arterial pressure
Myocardial contractility
Vasodilation (arterial and venous)
Enhances catecholamine-associated
arrhythmias
Not inherently arrhythmogenic
http://www.za
zzle.com/got_
propofol_shirt
-
23546131003
3221603
Anticholinergics
Block presynaptic muscarinic cholinergic
receptors and parasympathetic nerve
terminals
facilitates NE and ACh release
Sinus tachycardia
Increased myocardial work
Decreased myocardial perfusion
Volatile inhalants
Dose-dependent CV effects
Direct myocardial depression
Decreased CO, blood pressure
Vasodilation HYPOTENSION
Decrease sympathoadrenal activity
Renin/angiotensin system may not respond normally
to hemorrhage
Partially obtunded baroreceptor reflexes
hypotension or hypovolemia may not cause
tachycardia
Cardiac diseases in dogs/cats
Congenital
Patent ductus arteriosus
Aortic or pulmonic stenosis
AV valve dysplasia
Septal defects
Acquired
Valvular endocardiosis
Hypertrophic cardiomyopathy (feline)
Dilated cardiomyopathy (canine)
Pulmonary hypertension
Heartworm disease
Dysrhythmias (noncardiac disease)

Overview
Cardiac function review
Cardiovascular effects of anesthetic
drugs
Cardiac diseases
General anesthetic considerations
Case examples
Cardiac murmurs
Intensity: Grade (I-VI out of VI)
Timing: systolic, diastolic
Location (point of maximal intensity:
Basilar/apical
Left/right
http://en.wikipedia.org/
wiki/Heart_murmur
Innocent murmurs
Innocent = functional
Mild turbulence within heart and great
vessels
Diminish by 4-5 months of age
Characteristics
Systolic
< III or IV/VI intensity
Intensity may change from day to day
Short duration, low-pitched/vibrating
Murmurs that are not innocent
>IV/VI intensity, precordial thrill, diastolic
Aortic and pulmonic stenosis
Narrowed aortic or pulmonic
outflow tracts
Systolic basilar murmur
CO depends primarily on HR
Positive inotropy doesnt increase
CO
Bradycardia decreased CO
Tachycardia may predispose to
ventricular arrhythmias
Very cautious use of anticholinergics
http://www.heart-valve-
surgery.com/aortic-stenosis-
valve-heart-narrowing.php
Pulmonic stenosis Anesthetic
recommendations
Avoid drugs that drastically change
heart rate
Anticholinergics
Alpha-2-agonists (xylazine,
dexmedetomidine)
Maintain preload to maintain stroke
volume
If fluid overload, result is ascites (this is less
critical than pulmonary edema)
5ml/kg/hr fluid rate
5ml/kg crystalloid boluses as needed for
hypotension
Aortic stenosis Anesthetic
considerations
Maintain heart rate
Avoid: ketamine, alpha-2-agonists
Use: opioids (maybe not fentanyl?)
Maintain adequate stroke volume
Fluid restriction
Good monitoring is key
TPR, ECG, Invasive blood pressure
Capnography


Myxomatous Valvular disease
Insufficiency or stenosis
impaired CO failure (if severe)
Great variability in severity and valves
involved
Preanesthetic work-up
Min database, chest films, +/- echo
Anesthetic goals
Maintain HR, contractility
Avoid vasocontriction (increases in
afterload)
http://www.dog-
obedience-training-
review.com/cavalier-king-
charles-spaniel.html
Valvular insufficiency anesthetic
guidelines
Skip morning dose of ACE inhibitor
Protocol:
Use opioids +/- benzodiazepines
Induce with ket/val or propofol (mild) or
etomidate/val (severe)
Conservative IV fluid therapy
Use anticholinergics with caution
BP monitoring +/- CVP
Contraindicated: -2-agonists
Bradycardia, increased afterload
Hypertrophic cardiomyopathy (feline)
Stiff LV, poor diastolic function
Mitral regurg and hypertension
Early disease
symptomatic (+/- murmur)
Progressive disease
Murmur, arrhythmias, dyspnea,
thromboembolic disease
Heart failure, sudden death with stress

http://www.statesymbolsu
sa.org/Maine/cat_maine_
coon.html
Anesthetic management (feline HCM)
Contraindicated drugs
Acepromazine
Decreases afterload reduced coronary
perfusion
Ketamine and anticholinergics
Increases myocardial O2 demand
Monitoring
TPR, indirect blood pressure, ECG
Ideal if symptomatic: direct blood pressure,
capnography, pulse oximetry
Ventilation for Fozzy: peak airway
pressure <15 cm H
2
O

Dilated cardiomyopathy (canine DCM)
Features
Systolic dysfunction
Increased end-systolic and end-diastolic
volumes eccentric hypertrophy
Poor myocardial contractility
+/- dysrhythmias
Atrial fibrillation
No atrial contraction (kick)
No atrial-ventricular synchrony low stroke
volume
DCM - Anesthetic recommendations
Delay elective procedures
Maintain contractility
Avoid negative inotropic drugs, e.g.
propofol, alpha-2-agonists
Maintain normal heart rate
Avoid drugs that cause tachycardia
(anticholinergics)
Avoid drugs that cause bradycardia
(alpha-2-agonists, high dose opioids)

DCM Anesthetic recommendations
Pre-operative: measure blood
pressure
Premeds: opioid/benzo combo
Induction drugs
Etomidate or neurolept combo
Ketamine = okay if paired with
benzodiazepine.
Maintenance with inhalant
Opioids decrease inhalant requirement

http://balilandandvilla.blogsp
ot.com/2012/08/doberman.ht
ml
Pulmonary hypertension (e.g.
heartworm disease)
Pulmonary hypertension
Avoid ketamine and dexmedetomidine
Good monitoring
Symptomatic HW disease
Dysrhythmias
Pulmonic embolic disease
Possible decreased CO
https://www.msu.edu/~silvar/h
eartworm.htm?pagewanted=al
l
Heartworm disease: anesthetic
recommendations
USE benzodiazepines and opioids
Avoid drugs that significantly increase
afterload
Dont use dexmedetomidine
Cautious with acepromazine
+/- Avoid drugs with documented link to
pulmonary hypertension
Ketamine
Oxymorphone
General anesthetic guidelines for
cardiac patients
Preoxygenate ~3-5 minutes
Good monitoring (case-appropriate)
TPR
Blood pressure!!
+/- ECG
+/- capnography
+/- pulse oximetry
Use multi-modal approach!
Drugs to use carefully in cardiac
patients
Drugs that cause tachy- or
bradycardia
Drugs that significantly change SVR
Drugs that decrease contractility
Drugs/techniques with a narrow
margin of safety
Mask induction (no premed)
High-dose acepromazine (>0.05mg/kg)
General anesthetic guidelines for
cardiac patients
+/- fluid restriction (2-5ml/kg/hr)
Depends on disease and procedure
Drugs almost always appropriate for cardiac
patients (with good monitoring!)
Opioids
Benzodiazepines
Etomidate
Regional/local anesthesia

General anesthetic guidelines for
cardiac disease
Keep procedure as short as possible
Post-op monitoring
Skip morning dose of ACE inhibitors
Reduce intraanesthetic
hypotension
http://shop.farmvet.com/P
harmacy/Pet_Pharmacy/E
nalapril-Maleate-Tablets
Summary
Anesthetic drugs have variable effects on
cardiovascular function
Safe anesthetic management depends on
Knowledge of these anesthetic drug effects
Knowledge of cardiac pathophysiology
Monitoring!
Good planning and organization!
There are no safe anesthetic
agents, there are no safe anesthetic
procedures. There are only safe
anesthetists. -Robert Smith, MD
And for those lingering questions or
difficult cases
The UGA Anesthesia service does
phone consultations! 800-861-7456
Erik Hofmeister, DVM MA DACVA, DECVAA
Jane Quandt, DVM MS DACVA DACVECC
Molly Shepard, DVM DACVA
Cynthia Trim, BVSc, MRCVS, DVA, DACVA,
DECVAA
Residents:
Jill Maney, VMD
Stephanie Kleine, DVM
References
Congdon JM, et al 2011. Evaluation of the sedative and cardiovascular effects of
intramuscular administration of dexmedetomidine with and without concurrent
atropine administration in dogs. 1;239(1):81-9.
Guyton and Hall. 2006. Textbook of Medical Physiology.
Tranquilli, Thurmon, Grimm. 2007. Lumb and Jones Veterinary Anesthesia and
Analgesia.
Tilley, Smith, Oyama, Sleeper. 2008. Manual of Canine and Feline Cardiology.
Lamont LA, et al. 2002. Doppler echocardiographic effects of medetomidine on
dynamic left ventricular outflow tract obstruction in cats. JAVMA 221 (9): 1276-
1281.
Cardiac cycle diagram: http://www.google.com/imgres?imgurl=http://2.bp.blogspot.com/_uiyskjNZYt8/TJW2uBf-
P2I/AAAAAAAACHc/efGjdpXNqwQ/s1600/Mechanical%2Band%2BElectrical%2BEvents%2Bof%2Bthe%2BCardiac%2BCycle.jpg&imgrefurl=http://medipptx.blogspot.com/2010
/09/mechanical-and-electrical-events-of_501.html&usg=__0wpCdLXkpAFTj2CZG4YKEB-
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ovh=185&hovw=272&tx=142&ty=105&page=1&ndsp=21&ved=1t:429,r:9,s:0&biw=1345&bih=585
Aortic stenosis diagram: http://www.google.com/imgres?imgurl=http://petheatlhinfo.com/wp-content/uploads/2011/01/Aortic-
Stenosis.gif&imgrefurl=http://petheatlhinfo.com/aortic-stenosis-
dogs.html&usg=__FmP2lWIklHLRucmlNSbSVBqI2GE=&h=350&w=350&sz=38&hl=en&start=0&sig2=fxyOUSz2-
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&hovw=225&tx=108&ty=134&page=1&ndsp=12&ved=1t:429,r:0,s:0
PDA diagram:
http://www.google.com/imgres?imgurl=http://health.stateuniversity.com/article_images/gem_04_img0496.jpg&imgrefurl=http://heal th.stateuniversity.com/pages/1146/P
atent-Ductus-
Arteriosus.html&usg=__RHxfb65ZXDu3dBE2B1FP3kSHPN4=&h=282&w=370&sz=22&hl=en&start=0&sig2=mMcAqGG1Q_Q4RAjfFTB9xQ&zoom=1&tbnid=5QFzhJv9hR-
JZM:&tbnh=121&tbnw=159&ei=glrLTd-
mPKTY0QGy7sHCBQ&prev=/search%3Fq%3Dpatent%2Bductus%2Barteriosus%26hl%3Den%26sa%3DX%26pwst%3D1%26rls%3Dcom.microsoft:en-us:IE-
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6&hovw=257&tx=144&ty=137&page=1&ndsp=23&ved=1t:429,r:5,s:0
http://php.med.unsw.edu.au/embryology/index.php?title=Advanced_-_Cardiac_Conduction
http://php.med.unsw.edu.au/embryology/index.php?title=Advanced_-_Cardiac_Conduction