Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Publication Date: August 1, 2014

Diagnosis

Table 2. Supplemental Preoperative Evaluation

Multivariate Risk Indices

A validated risk-prediction tool can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery. ( B , IIa )
701
For patients with a low risk of perioperative MACE, further testing is NOT recommended before the planned operation. ( B , III (no benefit) )
701

The 12-lead ECG

Preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery. ( B , IIa )
701
Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery. ( B , IIb )
701
Routine preoperative resting 12-lead ECG is NOT useful for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery. ( B , III (no benefit) )
701

Assessment of LV function

It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function. ( C , IIa )
701
It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function. ( C , IIa )
701
Reassessment of LV function in clinically stable patients with previously documented LV dysfunction may be considered if there has been no assessment within a year. ( C , IIb )
701
Routine preoperative evaluation of LV function is NOT recommended. ( B , III (no benefit) )
701

Exercise stress testing for myocardial ischemia and functional capacity

For patients with elevated risk and excellent (>10 METs) functional capacity, it is reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery. ( B , IIa )
701
For patients with elevated risk and unknown functional capacity it may be reasonable to perform exercise testing to assess for functional capacity if it will change management. ( B , IIb )
701
For patients with elevated risk and moderate to good (≥4 METs to 10 METs) functional capacity, it may be reasonable to forgo further exercise testing with cardiac imaging and proceed to surgery. ( B , IIb )
701
For patients with elevated risk and poor or unknown functional capacity it may be reasonable to perform exercise testing with cardiac imaging to assess for myocardial ischemia. ( C , IIb )
701
Routine screening with noninvasive stress testing is NOT useful for patients at low-risk for noncardiac surgery. ( B , III (no benefit) )
701

Cardiopulmonary exercise testing

Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown. ( B , IIb )
701

Noninvasive pharmacological stress testing before noncardiac surgery

It is reasonable for patients who are at elevated risk for noncardiac surgery and have poor functional capacity (<4 METs) to undergo either DSE or MPI noninvasive pharmacological stress testing (either DSE or pharmacological stress MPI) if it will change management. ( B , IIa )
701
Routine screening with noninvasive stress testing is NOT useful for patients undergoing low-risk noncardiac surgery. ( B , III (harm) )
701

Preoperative coronary angiography

Routine preoperative coronary angiography is NOT recommended. ( C , III (no benefit) )
701

Table 3. Valvular Heart Disease, CIEDs and Pulmonary Vascular Disease

Valvular Heart Disease

It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation. ( C , I )
701
For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk. ( C , I )
701

Aortic Stenosis

Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis. ( B , IIa )
701

Mitral Stenosis

Elevated-risk elective noncardiac surgery using appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable in asymptomatic patients with severe mitral stenosis if valve morphology is not favorable for percutaneous mitral balloon commissurotomy. ( C , IIb )
701

Aortic and Mitral Regurgitation

Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe MR. ( C , IIa )
701
Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe AR and a normal LVEF. ( C , IIa )
701

CIEDs

Before elective surgery in a patient with a CIED, the surgical/procedure team and clinician following the CIED should communicate in advance to plan perioperative management of the CIED. ( C , I )
701
Patients with ICDs who have preoperative reprogramming to inactivate tachytherapy should be on a cardiac monitor continuously during the entire period of inactivation, and external defibrillation equipment should be available. Systems should be in place to ensure that ICDs are reprogrammed to active therapy before discontinuation of cardiac monitoring and discharge from the facility. ( C , I )
701

Pulmonary Vascular Disease

Chronic pulmonary vascular targeted therapy (i.e., phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, and prostanoids) should be continued unless contraindicated or not tolerated in patients with pulmonary hypertension who are undergoing noncardiac surgery. ( C , I )
701
Unless the risks of delay outweigh the potential benefits, preoperative evaluation by a pulmonary hypertension specialist before noncardiac surgery can be beneficial for patients with pulmonary hypertension, particularly for those with features of increased perioperative risk.a ( C , IIa )
a Features of increased perioperative risk in patients with pulmonary hypertension include:
1) diagnosis of Group 1 pulmonary hypertension (i.e., pulmonary arterial hypertension),
2) other forms of pulmonary hypertension associated with high pulmonary pressures (pulmonary artery systolic pressures >70 mm Hg) and/or moderate or greater right ventricular dilatation and/or dysfunction and/or pulmonary vascular resistance >3 Wood units, and
3) World Health Organization/New York Heart Association class III or IV symptoms attributable to pulmonary hypertension.
701

Treatment

Table 4. Perioperative Therapy

Coronary revascularization before noncardiac surgery

Revascularization before noncardiac surgery is recommended in circumstances in which revascularization is indicated according to existing CPGs. ( C , I )
701
It is NOT recommended that routine coronary revascularization be performed before noncardiac surgery exclusively to reduce perioperative cardiac events. ( B , III (no benefit) )
701

Timing of elective noncardiac surgery in patients with previous PCI

Elective noncardiac surgery should be delayed 14 days after balloon angioplasty and 30 days after BMS implantation.
14 days after balloon angioplasty ( C , I )
701
30 days after BMS implantation ( B , I )
701
Elective noncardiac surgery should optimally be delayed 365 days after DES implantation. ( B , I )
701
In patients in whom noncardiac surgery is required, a consensus decision among treating clinicians as to the relative risks of discontinuation or continuation of antiplatelet therapy can be useful. ( C , IIa )
701
Elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis.a ( B , IIb )
701
Elective noncardiac surgery should NOT be performed within 30 days after BMS implantation or within 12 months after DES implantation in patients in whom dual antiplatelet therapy will need to be discontinued perioperatively. ( B , III (harm) )
701
Elective noncardiac surgery should NOT be performed within 14 days of balloon angioplasty in patients in whom aspirin will need to be discontinued perioperatively. ( C , III (harm) )
701

Perioperative beta-blocker therapy

Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically. ( B , I )
SRb
701
It is reasonable for the management of beta blockers after surgery to be guided by clinical circumstances, independent of when the agent was started. ( B , IIa )
SRb
701
In patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification tests, it may be reasonable to begin perioperative beta blockers. ( C , IIb )
SRb
701
In patients with ≥3 RCRI risk factors (e.g., diabetes mellitus, HF, coronary artery disease, renal insufficiency, cerebrovascular accident), it may be reasonable to begin beta blockers before surgery. ( B , IIb )
SRb
701
In patients with a compelling long-term indication for beta-blocker therapy but no other RCRI risk factors, initiating beta blockers in the perioperative setting as an approach to reduce perioperative risk is of uncertain benefit. ( B , IIb )
SRb
701
In patients in whom beta-blocker therapy is initiated, it may be reasonable to begin perioperative beta blockers long enough in advance to assess safety and tolerability, preferably >1 day before surgery. ( B , IIb )
SRb
701
Beta-blocker therapy should NOT be started on the day of surgery. ( B , III (harm) )
SRb
701

Perioperative statin therapy

Statins should be continued in patients currently taking statins and scheduled for noncardiac surgery. ( B , I )
701
Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery. ( B , IIa )
701
Perioperative initiation of statins may be considered in patients with clinical indications according to GDMT who are undergoing elevated-risk procedures. ( C , IIb )
701

Alpha-2 agonists

Alpha-2 agonists for prevention of cardiac events are NOT recommended in patients who are undergoing noncardiac surgery. ( B , III (no benefit) )
701

ACE inhibitors

Continuation of ACE inhibitors or ARBs perioperatively is reasonable. ( B , IIa )
701
If ACE inhibitors or ARBs are held before surgery, it is reasonable to restart as soon as clinically feasible postoperatively. ( C , IIa )
701

Antiplatelet agents

Continue DAPT in patients undergoing urgent noncardiac surgery during the first 4-6 weeks after BMS or DES implantation, unless the risk of bleeding outweighs the benefit of stent thrombosis prevention. In patients undergoing urgent noncardiac surgery during the first 4-6 weeks after BMS or DES implantation, dual antiplatelet therapy should be continued unless the relative risk of bleeding outweighs the benefit of the prevention of stent thrombosis. ( C , I )
701
In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y12 platelet receptor–inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor–inhibitor be restarted as soon as possible after surgery. ( C , I )
701
Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis. ( C , I )
701
In patients undergoing nonemergency/nonurgent noncardiac surgery without prior coronary stenting who have not had previous coronary stenting, it may be reasonable to continue aspirin when the risk of increased cardiac events outweighs the risk of increased bleeding. ( B , IIb )
701
Initiation or continuation of aspirin is NOT beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting.
701
If risk of ischemic events outweighs risk of surgical bleeding ( C , III (no benefit) )
701
a Because of new evidence, this is a new recommendation since the publication of the 2011 PCI CPG.
b These recommendations have been designated with bSR to emphasize the rigor of support from the ERC’s systematic review.

Table 5. Anesthetic Consideration and Intraoperative Management

Volatile general anesthesia versus total intravenous anesthesia

Use of either a volatile anesthetic agent or total intravenous anesthesia is reasonable for patients undergoing noncardiac surgery, and the choice is determined by factors other than the prevention of myocardial ischemia and MI. ( A , IIa )
701

Perioperative pain management

Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI. ( B , IIa )
701
Preoperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with hip fracture. (B)
701

Prophylactic intraoperative nitroglycerin

Prophylactic intravenous nitroglycerin is NOT effective in reducing myocardial ischemia in patients undergoing noncardiac surgery. ( B , III (no benefit) )
701

Intraoperative monitoring techniques

Emergency use of perioperative TEE is reasonable in patients with hemodynamic instability undergoing noncardiac surgery to determine the cause of hemodynamic instability when it persists despite attempted corrective therapy, if expertise is readily available. ( C , IIa )
701
Routine use of intraoperative TEE during noncardiac surgery to screen for cardiac abnormalities or to monitor for myocardial ischemia is NOT recommended in patients without risk factors or procedural risks for significant hemodynamic, pulmonary, or neurologic compromise. ( C , III (no benefit) )
701

Maintenance of body temperature

Maintenance of normothermia may be reasonable to reduce perioperative cardiac events in patients undergoing noncardiac surgery. ( B , IIb )
701

Hemodynamic assist devices

Use of hemodynamic assist devices may be considered when urgent or emergency noncardiac surgery is required in the setting of acute severe cardiac dysfunction (i.e., acute MI, cardiogenic shock) that cannot be corrected before surgery. ( C , IIb )
701

Perioperative use of pulmonary artery catheters

The use of pulmonary artery catheterization may be considered when underlying medical conditions that significantly affect hemodynamics (i.e., HF, severe valvular disease, combined shock states) cannot be corrected before surgery. ( C , IIb )
701
Routine use of pulmonary artery catheterization in patients, even those with elevated risk, is NOT recommended. ( A , III (no benefit) )
701

Table 6. Surveillance and Management for Perioperative MI

Measurement of troponin levels is recommended in the setting of signs or symptoms suggestive of myocardial ischemia or MI. ( A , I )
701
Obtaining an ECG is recommended in the setting of signs or symptoms suggestive of myocardial ischemia, MI, or arrhythmia. ( B , I )
701
The usefulness of postoperative screening with troponin levels in patients at high risk for perioperative MI, but without signs or symptoms suggestive of myocardial ischemia or MI, is uncertain in the absence of established risks and benefits of a defined management strategy. ( B , IIb )
701
The usefulness of postoperative screening with ECGs in patients at high risk for perioperative MI, but without signs or symptoms suggestive of myocardial ischemia, MI, or arrhythmia, is uncertain in the absence of established risks and benefits of a defined management strategy. ( B , IIb )
701
Routine postoperative screening with troponin levels in unselected patients without signs or symptoms suggestive of myocardial ischemia or MI is NOT useful for guiding perioperative management. (B, III (no benefit))
701

Recommendation Grading

Disclaimer

Overview

Title

Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Authoring Organizations

Endorsing Organizations

Publication Month/Year

August 1, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D019990 - Perioperative Care, D002318 - Cardiovascular Diseases

Keywords

cardiovascular, perioperative care, anesthesia and analgesia

Supplemental Methodology Resources

Systematic Review Document

Methodology

Number of Source Documents
491
Literature Search Start Date
April 1, 2013
Literature Search End Date
July 1, 2014