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The decision to use regional anesthesia can be a complex medical choice. Preexisting medical conditions, type of surgery, anesthetic risks, and patient characteristics all may have a profound impact on anesthetic choice and perioperative management. In patients with cardiovascular disease, regional anesthesia techniques (either alone or in conjunction with general anesthesia) can offer the potential perioperative benefits of stress response attenuation, cardiac sympathectomy, earlier extubation, shorter hospital stay, and intense postoperative analgesia.

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Neuraxial anesthesia has been shown to be useful in treating patients with coronary artery disease. This includes treatment of anginal symptoms, primary (or part of a combined) anesthetic for the surgical procedure, and acute postoperative pain management. Its use in the high-risk patient during noncardiac surgery can offer reduced blood loss and need for transfusion and a decreased incidence of thromboembolic events.

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Regional anesthetic options are not limited to neuraxial techniques when dealing with patients with cardiovascular disease. Paravertebral block has also been used as an adjunct to general anesthesia in the management of patients undergoing cardiac surgery. In addition, intercostal nerve blockade and parasternal block can be used for postoperative pain relief in patients after cardiac surgery. Cervical plexus block can be used in the anesthetic management of patients undergoing carotid endarterectomy. Lower extremity blocks, such as combined sciatic–femoral nerve block can also be used in high-risk patients in whom even modest alterations in hemodynamics would not be tolerated.

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Local anesthetics alone or in combination with narcotics are used for regional anesthesia in patients with cardiovascular disease. Ropivacaine is a commonly used local anesthetic during neuraxial anesthesia for cardiac surgery. Although its pharmacologic properties, including onset of action and duration of action, are essentially the same as those of bupivacaine, ropivacaine possesses less cardiotoxic properties, produces less central nervous system depression, and is associated with less motor blockade. Ropivacaine is often combined with sufentanil when used during epidural administration for cardiac surgery. Intrathecal narcotics in combination with general anesthesia can provide intraoperative and postoperative analgesia. The most common undesirable effects of intrathecal opioids are respiratory depression, nausea and vomiting, pruritus, and urinary retention. However, advances in narcotic formulations may allow for sustained-release delivery and target-specific affinity, which may reduce the potential of common narcotic side effects. Standard local anesthetic preparations are used in performing upper and lower extremity blocks in patients with cardiovascular disease.

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The most severe complication from neuraxial anesthesia is epidural hematoma formation. The incidence of hematoma formation ranges from 1:150,000 after epidural instrumentation to 1:220,000 for intrathecal instrumentation. Risk of hematoma formation after either technique is increased if performed before systemic heparinization. Currently, only a minority of practicing anesthesiologists use neuraxial blockade in the management of patients undergoing cardiac surgery. Patients presenting for major noncardiac surgery often receive anticoagulation to prevent venous thrombosis and pulmonary embolism. It appears that anesthesiologists more frequently perform neuraxial blockade on these patients after weighing the risk of hematoma formation against the benefits.

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