Precise perioperative assessment and anesthesia strategy for painless gastrointestinal endoscopy in high-risk cardiovascular disease patients

Patients with cardiovascular disease (CVD) are at substantially increased risk during painless gastrointestinal endoscopy (PGE). Cardiopulmonary comorbidities, bowel preparation-related hypovolemia, and procedural stressors contribute to hemodynamic and respiratory instability. The conventional American Society of Anesthesiologists (ASA) physical status classification incompletely captures these dynamic risk factors and may fail to identify up to 42% of high-risk patients, contributing to a markedly increased incidence of anesthesia-related adverse events. We propose a bundled, physiology-driven perioperative strategy to improve safety in high-risk CVD patients undergoing PGE. This approach incorporates four key components. First, dynamic risk stratification using nomogram-based models (c-statistic up to 0.79) integrates cardiopulmonary and end-organ reserve (CPER), procedural variables, and biomarker trajectories, outperforming static ASA classification. Second, cardiovascular risk-adapted pharmacologic strategies prioritize hemodynamically stable regimens, favoring dexmedetomidine-ketamine over propofol-opioid combinations in patients with reduced left ventricular ejection fraction, and applying albumin-adjusted dosing in hepatic dysfunction (e.g., remimazolam ED₉₅ = 0.107 mg/kg in Child-Pugh B cirrhosis). Third, precision intraoperative monitoring, including invasive arterial pressure, stroke volume variation, and capnography, enables early identification and targeted management of hypotension and hypoxemia. Finally, physiology-based discharge criteria emphasizing hemodynamic stability, respiratory adequacy, and neurologic recovery reduce delayed complications and unplanned readmissions. Transitioning from static preprocedural assessment to dynamic physiologic management substantially enhances perioperative safety in high-risk cardiovascular patients undergoing PGE. Integrating predictive risk models, tailored pharmacology, advanced monitoring, and physiology-based discharge protocols is associated with meaningful reductions in cardiopulmonary complications. Future randomized trials are needed to validate pharmacogenomic-guided dosing and closed-loop sedation systems, but maintaining hemodynamic stability (mean arterial pressure ≥ 65 mmHg) remains a central priority for improving outcomes in this vulnerable population.