Cardiac assessment and management in older surgical patients.

Abstract

The aging global population has a profound impact on patient management in the perioperative setting. Older patients represent an ever-growing proportion of patients presenting for surgery, 1 and face an elevated risk for adverse outcomes. The elevated risk is explained by a high burden of comorbid disease associated with elevated age (eg, cardiovascular disease), age-associated geriatric syndromes (eg, frailty), and physiological changes directly related to aging. Cellular senescence explains many of these changes. Human cells only replicate a fi nite number of times; telomere shortening occurs during every replication cycle, thereby exposing DNA to damage. 2 Reduced regenerative capacity, along with other changes at a molecular and cellular level (eg, free radical pro-duction), result in pathophysiological changes seen in old age. In the cardiovascular system, aging results in loss of vascular compliance, endothelial dysfunction, changes in cardiac structure and function (myocardial remodeling, diastolic dysfunction, cardiac conduction system degeneration), and altered cardiac response to stress (eg, attenuated baroreceptor response). 3,4 These changes culminate in reduced cardiovascular function and reduced capacity to respond to acute physiological stressors. Preoperative cardiac assessment of older adults should address the sequalae of these age-related changes. In this review, we discuss several cardiac conditions especially relevant to older surgical patients (ie, hypertension, ischemic heart disease (IHD)]. We also address the role of multidimensional geriatric assessment as a component of high-quality preoperative evaluation.