Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Publication Date: August 1, 2014

Key Points

Key Points

  1. The aims of preoperative evaluation in the patient undergoing noncardiac surgery are:
    1. Assessment of perioperative risk (which can be used to inform the decision to proceed or the choice of surgery and which includes the patient’s perspective),
    2. Determination of the need for changes in management, and
    3. Identification of cardiovascular conditions or risk factors requiring longer-term management.
  2. A validated risk-prediction tool (e.g., ACSNSQIP risk calculator and Lee Revised Cardiac Risk Index) can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery.
  3. In the absence of a coronary intervention, ≥60 days should elapse after a myocardial infarction before noncardiac surgery is undertaken.
  4. The decision to perform further cardiovascular testing depends upon the urgency of surgery, assessment of risk based upon the combination of surgical and clinical factors, and functional status. Risk is dichotomized into low (<1% incidence of MACE) and elevated risk.
  5. Testing should only be performed if it changes management.
  6. Elective noncardiac surgery should optimally be delayed 365 days after DES implantation. With the newer-generation DES, 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.
  7. The only Class I indication for perioperative beta-blocker therapy is that therapy should be continued in patients undergoing surgery who have been on beta-blockade chronically. Active management of patients on beta blockers is required during and after surgery. Particular attention should be paid to the need to modify or temporarily discontinue beta blockers as clinical circumstances (e.g., hypotension, bradycardia, bleeding) dictate.
  8. 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.

Diagnosis

...iagnosis

...able 1. Definitions of Urgency and Ris...


...epwise Approach to Perioperative Ca...


...e 2. Supplemental Preoperative Evaluati...

...iate Risk Indices...

...ed risk-prediction tool can be useful in predictin...

...with a low risk of perioperative MACE, furt...

...12-lead E...

...e resting 12-lead ECG is reasonable...

...tive resting 12-lead ECG may be considered for a...

...ne preoperative resting 12-lead ECG is...

...nt of LV function...

...onable for patients with dyspnea of unknow...

...able for patients with HF with worsening...

...ent of LV function in clinically stable patie...

...utine preoperative evaluation of LV...

...ess testing for myocardial ischemia...

...or patients with elevated risk and excellent...

...tients with elevated risk and unknown functiona...

...s with elevated risk and moderate to good (≥4 ME...

...s with elevated risk and poor or unknown functi...

...creening with noninvasive stress testin...

...lmonary exercise testing...

...opulmonary exercise testing may be considered f...

...vasive pharmacological stress testing be...

...asonable for patients who are at elevated risk...

...ening with noninvasive stress testing is NOT...

...ative coronary angiogr...

...ative coronary angiography is NOT recom...


...Valvular Heart Disease, CIEDs and Pulmonary...

...ular Heart Disease...

...t is recommended that patients with...

...ho meet standard indications for valvular...

Aortic Stenosi...

...-risk elective noncardiac surgery with approp...

...itral Stenosi...

...elective noncardiac surgery using a...

...and Mitral Regurgitation...

...isk elective noncardiac surgery with app...

...k elective noncardiac surgery with appropriate...

...IEDs...

...surgery in a patient with a CIED, the surgi...

Patients with ICDs who have preoperative r...

...monary Vascular Dise...

...onary vascular targeted therapy (i.e., phospho...

...the risks of delay outweigh the potential benef...


Treatment

...eatmen...

...e 4. Perioperative Therapy...

...larization before noncardiac surgery...

...cularization before noncardiac surgery is re...

...is NOT recommended that routine coronary re...

...f elective noncardiac surgery in patients wi...

...er balloon angioplasty ( C , I )701...

...ter BMS implantation ( B , I )701...

...noncardiac surgery should optimally be delaye...

...tients in whom noncardiac surgery is required...

...ve noncardiac surgery after DES im...

...e noncardiac surgery should NOT be performed...

...ardiac surgery should NOT be performe...

...operative beta-blocker the...

...blockers should be continued in patients undergoi...

...s reasonable for the management of beta blockers...

...tients with intermediate- or high-risk myocar...

...tients with ≥3 RCRI risk factors (e.g...

...atients with a compelling long-term indicat...

...n whom beta-blocker therapy is initiated,...

...ker therapy should NOT be started...

...erioperative statin therapy

...ould be continued in patients currently taking...

...ve initiation of statin use is reasonabl...

...initiation of statins may be considered in patien...

...a-2 agonists...

...for prevention of cardiac events...

...CE inhibitors

...ion of ACE inhibitors or ARBs perioper...

...ACE inhibitors or ARBs are held before surgery,...

...latelet agent...

...n patients undergoing urgent noncardiac surge...

In patients who have received coronary sten...

...t of the perioperative antiplatelet therapy should...

...undergoing nonemergency/nonurgent noncard...

...01

...ischemic events outweighs risk of sur...

...Because of new evidence, this is a new...


...igure 2. Algorithm for Antiplatelet Management in...


...Anesthetic Consideration and Intraop...

Volatile general anesthesia versus total i...

...ther a volatile anesthetic agent or total in...

...rative pain management...

...axial anesthesia for postoperative...

...epidural analgesia may be considered t...

...intraoperative nitroglycerin...

...ntravenous nitroglycerin is NOT effectiv...

...ive monitoring techniques...

...gency use of perioperative TEE is reasonable...

...outine use of intraoperative TEE during...

...e of body temperature...

...of normothermia may be reasonable to...

...ynamic assist devices...

...ic assist devices may be considered when u...

...se of pulmonary artery catheters...

...he use of pulmonary artery catheterization may b...

...se of pulmonary artery catheterization in pa...


...rveillance and Management for Perioperative MI...

...urement of troponin levels is recom...

...an ECG is recommended in the settin...

...fulness of postoperative screening with tropo...

...he usefulness of postoperative screening with EC...

...utine postoperative screening with troponin le...