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 ED