Heart failure and reduced ejection fraction
Stem
A 68-year-old man, 84 kg, with ischemic cardiomyopathy and an ejection fraction of 25% is scheduled for open right hemicolectomy for colon cancer. He walks one block before stopping, sleeps on one pillow and has no edema. He takes sacubitril-valsartan, carvedilol, spironolactone, empagliflozin and furosemide. Blood pressure is 102/64, heart rate 64, creatinine 1.4 mg/dL and potassium 4.9 mEq/L.
Question
How will you prepare him for surgery and conduct the anesthetic?
Ideal answer
HeadlineSevere HFrEF; first I confirm he is compensated, because decompensation postpones elective surgery. Cancer surgery can wait days for diuresis, not months.1
- No new echo unless symptoms changed; he has no orthopnea, edema or new dyspnea.1
- Continue carvedilol; continuing sacubitril-valsartan is reasonable, accepting vasopressor support after induction.1 Empagliflozin must have stopped 3–4 days before; the hold avoids perioperative metabolic acidosis, and if missed, I discuss delay.2
- Hold furosemide that morning; check potassium, given spironolactone and his creatinine.
- Arterial line before induction, pads if a device; slow induction: norepinephrine running, etomidate or reduced propofol plus fentanyl, because his output is preload- and afterload-sensitive and vasodilation drops pressure fast.
- Fluids by stroke-volume variation or TEE, not CVP, avoiding both overload and deep hypovolemia.
Watch for: congestion after day two; monitored bed, medicines restarted once euvolemic and normotensive.
Breaking down the answer
- Compensated or not — the guideline lists decompensated heart failure among active conditions that delay elective surgery; HFrEF and symptoms both raise risk.1 Changes if: rales, a third heart sound or rising weight, and I delay and diurese.
- Know the category — HFrEF is an ejection fraction of 40% or less, mildly reduced 41–49%, preserved 50% or more.3 It shows I understand which drugs he is on and why.
- Four pillars — renin-angiotensin inhibition (sacubitril-valsartan first line), a beta-blocker, a mineralocorticoid antagonist, an SGLT2 inhibitor.3 Stopping the beta-blocker invites tachycardia and ischemia; the SGLT2 hold is the one deliberate exception, and missing it means euglycemic ketoacidosis.2
- Why norepinephrine — with an angiotensin-neprilysin inhibitor on board, post-induction hypotension is expected; norepinephrine adds beta-1 support a pure alpha agonist lacks. Changes if refractory: vasopressin.
- Flat Starling curve — a failing ventricle turns extra volume into congestion, not output, so dynamic indices or TEE guide boluses; CVP misleads in a dilated ventricle.
- Analgesia and the bed — a thoracic epidural gives good analgesia if loaded slowly; reabsorption of fluid on day two or three pushes him into pulmonary edema if no one watches weight and output.
Follow-up question
Ninety minutes into the case, mean arterial pressure falls to 52 despite norepinephrine at 0.15 mcg/kg/min. TEE shows a dilated, globally hypokinetic left ventricle with a full chamber and no new regional wall-motion change. What do you do?
Follow-up answer
HeadlineLow-output failure, not hypovolemia or vasoplegia: the ventricle is full, barely moving. I tell the surgeon to pause and pack, and call for help.
I ask for a second infusion pump and check depth, blood gas, potassium, calcium, hemoglobin and an ECG for ischemia or arrhythmia. I add an inotrope, dobutamine or milrinone, the agents for low-output heart failure, keeping norepinephrine to hold perfusion pressure if milrinone vasodilates.4 No more fluid; if congested, a diuretic.4 I reassess with TEE and the arterial waveform, trend lactate, and if he does not respond I call cardiology about mechanical support. He goes to the ICU.
Pitfalls that cost points
- Treating every low pressure with fluid.
- Stopping the beta-blocker the morning of surgery.
Rapid-fire
Q: What does a BNP below 100 pg/mL rule out? A: Not heart failure with preserved ejection fraction; up to 30% of acute HFpEF patients fall below that threshold.4
Q: What is the mainstay of treating acute decompensation? A: Diuretics, with nitrates to reduce congestion.4
Q: Why etomidate in this patient? A: It preserves sympathetic tone and contractility better than propofol, so the pressure drop at induction is smaller.
Q: What is HFimpEF? A: A prior ejection fraction of 40% or less that has improved to above 40% on follow-up.3
Numbers to know
| Item | Value |
|---|---|
| HFrEF | EF 40% or less3 |
| HFmrEF | EF 41–49%3 |
| HFpEF | EF 50% or more3 |
| SGLT2 inhibitor hold | 3–4 days before surgery2 |
| BNP threshold | 100 pg/mL; misses up to 30% of acute HFpEF4 |
Links
- Preoperative cardiac evaluation for non-cardiac surgery, Vasopressors and inotropes: choosing and titrating, Intraoperative hypotension: differential and management, Pacemakers and ICDs in the operating room, The patient with an LVAD
- Atlas: Ventricular function and wall motion
- 2024 AHA/ACC perioperative guideline; 2022 AHA/ACC/HFSA heart failure guideline
Sources
- 1.2024 ACC/AHA guideline on perioperative cardiovascular management before noncardiac surgery: What's new? · Cleveland Clinic Journal of Medicine, 2025 · ccjm.orgCohn SL, CCJM 92(4), April 2025. GDMT continued; reasonable to continue RAS inhibitors in HFrEF; decompensated HF postpones elective surgery; TTE for new or worsening dyspnea.
- 2.2024 AHA/ACC Perioperative CV Management Guideline: Key Points · American College of Cardiology, 2024 · acc.org
- 3.2022 AHA/ACC/HFSA Heart Failure Guideline: Key Perspectives · American College of Cardiology, 2022 · acc.org
- 4.Heart Failure (HF) · Merck Manual Professional Edition · merckmanuals.com
Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.