Congestive Heart Failure (CHF)

Know the ventricle and its numbers - Get the ejection fraction, functional class, and whether it's systolic or diastolic; review the recent echo, BNP, and the current diuretic and guideline-directed medical regimen.

Protect the pump - A failing heart tolerates myocardial depression poorly. Titrate induction agents slowly; etomidate is the hemodynamically gentle choice.

Volume tightrope - The ventricle needs adequate preload but decompensates with overload. Give fluids judiciously and watch for pulmonary edema.

Afterload and rate - Avoid abrupt afterload spikes, and maintain a controlled heart rate and sinus rhythm. Have inotropes and vasopressors drawn up.

Monitoring - Consider an arterial line for beat-to-beat pressure in moderate-to-severe disease, and more advanced monitoring (TEE, cardiac output) for major cases.

Regional and emergence - Neuraxial can help by reducing afterload but will drop preload if the sympathectomy is abrupt. Aim for a smooth, well-analgesic emergence — tachycardia and hypertension add work the ventricle can't afford.

Heart failure is a syndrome in which the heart cannot pump enough to meet the body's demands, from impaired ventricular filling (diastolic) or ejection (systolic).

Chronic low output drives neurohormonal activation (sympathetic and renin-angiotensin-aldosterone) that produces fluid retention, ventricular remodeling, and rising filling pressures. Patients present with fatigue, dyspnea, reduced exercise tolerance, and pulmonary and peripheral edema. The failing ventricle is preload-dependent yet intolerant of volume overload, sensitive to afterload, and prone to arrhythmias — a narrow window that anesthesia can easily push out of balance.