Heart Failure: Mechanisms, Treatment, and Anesthesia Management

Xianfeng Ren , Wei Dong Gao
J Anesth Perioper Med 2018; 5(4): 186- 199 . Published on Jul 28, 2018 . doi:10.24015/JAPM.2018.0074
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Aim of review: To update our understanding of the pathogenesis and mechanisms of heart failure with reduced ejection fraction (HFrEF), treatment, and issues pertaining to the perioperative care of these patients. 
Methods: We conducted a comprehensive review of the current literature, including both original basic and clinical studies on HFrEF from basic mechanisms of its development to clinical treatments. We used PubMed as the main database. We found over 5000 publications with the keyword “heart failure with reduced ejection fraction,” including original research, meta-analyses, and review studies. We selected recent reviews, recent original studies (basic and clinical), and past landmark original studies (basic and clinical) over the past 10 years. We also reviewed the literature on some specific issues regarding the perioperative care of patients with heart failure.
Recent findings: HFrEF presents perioperative challenges to anesthesiologists. It is characterized by chamber dilatation with low contractility and altered cardiac excitation-contraction coupling processes. Treatments for HFrEF consist of angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers and β blockers at early stages, and device therapies and heart transplantation at more advanced stages. Novel therapies are being investigated as well. Specific perioperative care for patients with HFrEF includes preoperative optimization, maximization of myocardial protection, minimization of myocardial injury, appropriate use of positive inotropic agents, proper fluid management, and management of device therapies. 
Summary: The pathophysiology of heart failure involves activation of multiple signaling pathways and significant alterations in excitation-contraction coupling. Perioperative care of patients with heart failure is challenging and requires an understanding of the basic mechanisms of heart failure. Moreover, practitioners should be able to stratify and minimize risk, optimize and manage compromised patients, and prevent the worsening of symptoms and complications. (Funded by the American Heart Association.)
Citation: Xianfeng Ren, Wei Dong Gao. Heart Failure: Mechanisms, Treatment, and Anesthesia Management. J Anesth Perioper Med 2018; 5 : 186 - 199. doi: 10.24015/JAPM.2018.0074
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