Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
Key Points
Key Points
- The aims of preoperative evaluation in the patient undergoing noncardiac surgery are:
- 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),
- Determination of the need for changes in management, and
- Identification of cardiovascular conditions or risk factors requiring longer-term management.
- 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.
- In the absence of a coronary intervention, ≥60 days should elapse after a myocardial infarction before noncardiac surgery is undertaken.
- 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.
- Testing should only be performed if it changes management.
- 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.
- 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.
- 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...
Table 1. Definitions of Urgency and RiskHaving...
...igure 1. Stepwise Approach to Perioperati...
Table 2. Supplemental Preoperative Evalu...
Multivariate Risk Indi...
...risk-prediction tool can be useful in predicting t...
...ith a low risk of perioperative MACE, further...
...12-lead EC...
...perative resting 12-lead ECG is reasonable for pa...
...operative resting 12-lead ECG may be consid...
...tine preoperative resting 12-lead ECG is NOT...
...nt of LV function...
...able for patients with dyspnea of un...
...reasonable for patients with HF with wo...
...of LV function in clinically stable...
...preoperative evaluation of LV function is NOT reco...
Exercise stress testing for myocardial ischem...
...r patients with elevated risk and excellent (>...
...or patients with elevated risk and u...
...ith elevated risk and moderate to go...
...with elevated risk and poor or unknown funct...
...ine screening with noninvasive stress testing is...
Cardiopulmonary exercise t...
...exercise testing may be considered for patie...
...pharmacological stress testing befor...
...reasonable for patients who are at elev...
...g with noninvasive stress testing is NOT...
...ative coronary angiography...
...operative coronary angiography is NOT rec...
...ular Heart Disease, CIEDs and Pulmonary Vascula...
...r Heart Disease...
...is recommended that patients with cli...
...adults who meet standard indications for...
...c Stenosis...
...evated-risk elective noncardiac surge...
...l Stenosis...
...risk elective noncardiac surgery using appropr...
...ic and Mitral Regurgitation
...levated-risk elective noncardiac surgery with...
...-risk elective noncardiac surgery with...
CIEDs
...ve surgery in a patient with a CIE...
...atients with ICDs who have preoperati...
...onary Vascular Disease...
Chronic pulmonary vascular targeted therapy (i.e.,...
...of delay outweigh the potential benef...
Treatment
...reatment
Table 4. Perioperative...
Coronary revascularization before noncardiac surg...
...larization before noncardiac surgery is recom...
...s NOT recommended that routine coronary revascul...
...ctive noncardiac surgery in patients...
...days after balloon angioplasty ( C ,...
...0 days after BMS implantation ( B...
...ive noncardiac surgery should opti...
...hom noncardiac surgery is required, a consensus d...
...iac surgery after DES implantation may be con...
...cardiac surgery should NOT be perform...
...lective noncardiac surgery should NOT be p...
...tive beta-blocker thera...
...a blockers should be continued in patients unde...
...ble for the management of beta blockers aft...
...with intermediate- or high-risk myocardial...
...s with ≥3 RCRI risk factors (e.g.,...
...with a compelling long-term indica...
...n whom beta-blocker therapy is initiated,...
...rapy should NOT be started on the d...
...rative statin therapy...
...tatins should be continued in patients currently...
...perative initiation of statin use is reasona...
...rative initiation of statins may be considered in...
...lpha-2 agoni...
...ists for prevention of cardiac eve...
...CE inhibit...
...on of ACE inhibitors or ARBs perioperatively...
...f ACE inhibitors or ARBs are held befor...
...ntiplatelet agen...
...inue DAPT in patients undergoing urgent noncardia...
...who have received coronary stents and must underg...
...of the perioperative antiplatelet therap...
...dergoing nonemergency/nonurgent non...
...01
If risk of ischemic events outweighs risk...
...cause of new evidence, this is a new reco...
...thm for Antiplatelet Management in Patients Wit...
...Anesthetic Consideration and Intraoperati...
...ile general anesthesia versus total intr...
...f either a volatile anesthetic agent or tota...
...operative pain manageme...
...euraxial anesthesia for postoperative pai...
...ive epidural analgesia may be considered to d...
...ophylactic intraoperative nitrogl...
Prophylactic intravenous nitroglycerin is NOT...
...tive monitoring techniques...
...ency use of perioperative TEE is reaso...
...use of intraoperative TEE during noncardia...
...e of body temperature...
...of normothermia may be reasonable to reduce per...
Hemodynamic assist devic...
...ynamic assist devices may be considered when...
...use of pulmonary artery catheters...
...use of pulmonary artery catheterization may be co...
...outine use of pulmonary artery catheterization in...
...ble 6. Surveillance and Management for Periop...
...ent of troponin levels is recommended in the setti...
...G is recommended in the setting of signs or sy...
...he usefulness of postoperative screenin...
...of postoperative screening with ECGs in pat...
...utine postoperative screening with...