Heart disease and vasoconstrictor anesthetics in HOF

Patients with heart disease show up in HOF offices more often than you might think: people with hypertension, coronary disease, arrhythmia, pacemakers, people on anticoagulants. The aesthetic procedure is elective, and safety comes first. One of the variables that raises the most questions is the anesthetic with a vasoconstrictor. This page summarizes, at a review level, why it calls for caution, how to do the assessment and how to record it. The choice of drug, the dose and the approach follow the package insert, the training and the decision of the qualified professional, in line with the rules of their professional board in Brazil, together with the treating physician when needed.

What is a vasoconstrictor and why is it used?

Many local anesthetics combine an anesthetic salt with a vasoconstrictor, usually epinephrine (adrenaline) or another agent. The vasoconstrictor reduces local blood flow, prolongs the anesthetic's duration, lowers systemic absorption and helps control bleeding. In HOF, anesthetics with a vasoconstrictor appear in nerve blocks and infiltrations, while topicals and fillers with lidocaine generally do not contain a vasoconstrictor. See local anesthesia in HOF: overview and hyaluronic acid with lidocaine.

Why does a patient with heart disease call for caution?

Epinephrine acts on receptors that increase heart rate, contractility and, in many cases, blood pressure. At local-use doses, the systemic effect is usually small, but it can become relevant with accidental intravascular injection, a high dose, rapid absorption or underlying heart disease. The risk is tachycardia, arrhythmia, a rise in blood pressure and, in high-risk patients, myocardial ischemia.

How do you conduct the medical history?

The medical history is the most important tool. Ask directly about:

• cardiovascular diagnoses, surgeries and hospital stays;
• recent symptoms: chest pain, shortness of breath, palpitations, dizziness, fainting;
• medications in use, including anticoagulants, antiarrhythmics, beta-blockers and antidepressants;
• usual blood pressure and whether it is controlled;
• previous reactions to local anesthetics, including at the dentist;
• use of stimulants, excess caffeine and supplements.

If in doubt, measuring blood pressure and heart rate before the procedure is a simple, informative step. See hypertensive crisis in the office and hypertension and bruising in HOF.

Is the anesthetic with a vasoconstrictor really needed?

The starting question is whether an injectable anesthetic is necessary at all. For most HOF procedures, comfort is achieved with topical anesthetic, ice, vibration and products containing lidocaine. When an injectable anesthetic is indicated, the options include versions without a vasoconstrictor, with a shorter duration and without the bleeding-control effect. The choice should weigh the gain in comfort against the patient's risk.

When should you ask the treating physician for clearance?

In general, clearance is recommended when there is known heart disease with recent symptoms, decompensated disease, a recent medication change, a prolonged procedure or use of a larger anesthetic volume. Clearance is not a "rubber stamp": it is a conversation. The professional describes the procedure, the type of anesthetic, the estimated dose and the context, and the physician assesses stability and any precautions. Attach the reply to the patient record. See patient record and documentation in HOF.

What about filler, toxin and biostimulator?

These products do not contain a vasoconstrictor, but the procedure can cause pain, anxiety and a vasovagal response, which also matter for a cardiac patient. Anxiety raises heart rate and blood pressure, and vasovagal syncope is a known event. See vasovagal syncope in the office, anxious patient during care and chest pain in the office. A comfortable position, a calm environment, clear communication and pauses help.

Additional caution: do not confuse vasoconstrictor blanching with ischemia

The vasoconstrictor can cause local blanching, which is often expected and temporary. In HOF, it can be mistaken for a sign of vascular occlusion in a filler procedure, which complicates the decision. Record what was injected, where and when, and watch how it evolves. See vascular occlusion vs anesthesia blanching.

Patients with a pacemaker, anticoagulant or other special situations

Some patients with heart disease bring additional issues. A patient with a pacemaker or implantable defibrillator should get guidance from the treating physician before any procedure that uses electrical equipment or energy, and the caution extends to devices used in aesthetics. An anticoagulated patient has a higher risk of bruising, and stopping the medication should never be decided by the HOF professional without talking to the prescribing physician. A patient on antiplatelet therapy may bleed more, and the elective procedure may be postponed or carried out with caution. See anticoagulants and injectable procedures and coagulation disorders in HOF.

Elderly patients with several conditions and several medications deserve extra attention, because interactions multiply and physiological reserve is lower. In those cases, simplifying the procedure, reducing the number of points and reducing the total anesthetic dose is usually a prudent approach. See patients aged 70 or older in HOF.

Preparing the room and the team

If there is a cardiac patient on the schedule, it is worth preparing the room in advance: a monitor or blood pressure cuff at hand, a pulse oximeter, quick access to the emergency kit, the referral service's phone number visible and the team aware of the case. Review the cardiac arrest protocol and the location of the defibrillator, when available. See cardiac arrest in the office and AED in the HOF office. None of these resources is used often, and that is precisely why the preparation has to be deliberate.

How do you record it?

In the patient record, note: cardiovascular history, medications, blood pressure and heart rate readings (if taken), the physician's clearance (when there is one), the choice of anesthetic and the total dose, any complications and the guidance given. The same rule applies to informed consent: the mention of cardiovascular risks must be clear for the patient with heart disease.

Where does Harmy fit in?