Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Publication Date: September 24, 2024

Overview

Overview

Top Take-Home Messages

  1. A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted.
  2. Cardiovascular screening and treatment of patients undergoing noncardiac surgery (NCS) should adhere to the same indications as nonsurgical patients, carefully timed to avoid delays in surgery and chosen in ways to avoid overscreening and overtreatment.
  3. Stress testing should be performed judiciously in patients undergoing NCS, especially those at lower risk, and only in patients in whom testing would be appropriate independent of planned surgery.
  4. Team-based care should be emphasized when managing patients with complex anatomy or unstable cardiovascular disease.
  5. New therapies for management of diabetes, heart failure, and obesity have significant perioperative implications. Sodium-glucose cotransporter 2 inhibitors should be discontinued 3 to 4 days before surgery to minimize the risk of perioperative ketoacidosis associated with their use.
  6. Myocardial injury after NCS is a newly identified disease process that should not be ignored because it portends real consequences for affected patients.
  7. Patients with newly diagnosed atrial fibrillation identified during or after NCS have an increased risk of stroke. These patients should be followed closely after surgery to treat reversible causes of arrhythmia and to assess the need for rhythm control and long-term anticoagulation.
  8. Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications and is not recommended in the majority of cases.
  9. In patients with unexplained hemodynamic instability and when clinical expertise is available, emergency focused cardiac ultrasound can be used for preoperative evaluation; however, focused cardiac ultrasound should not replace comprehensive transthoracic echocardiography.

Definitions and Calculators

...itions and Calculator...

...The numbering of the following tables and f...


...e 2. Definitions of Surgical Timing and Surgical...


.... Risk Calculator...

 3.1. Cardiovascular Risk Indices In patien...


...Risk Scores and CalculatorsHaving trouble viewi...


Assessment

Assessm...

...apacity Assessment In patients underg...


...ke Activity Status Index (DASI)Having trouble vie...


...railty In all patients ≥65 years of age and...


...ilty Assessment ToolsHaving trouble viewing...


...eoperative Biomarkers for Risk Str...

...In patients with known CVD, or age ≥65 y...

...patients with known CVD, or age ≥65...


...perative Cardiovascular Diagnostic Testing...

...Lead Electrocardiogram...

...s with known coronary heart diseas...

...ients undergoing NCS with a preoperative EC...

...For asymptomatic patients undergoing elevated-r...

...r asymptomatic patients undergoing lo...

....2. Assessment of Ventricular Func...

...1. Left Ventricular Function...

...patients undergoing NCS with new dyspnea, phy...

...s with a known diagnosis of HF with wors...

...matic and clinically stable patients undergoing...

...3. Stress Testing...

...patients undergoing elevated-risk NC...

...ho are at low risk for perioperati...

...1. Modality Selection for Stre...

...able 7. Considerations and Contraind...

...ry Computed Tomography Angiograp...

...patients undergoing elevated-risk surgery w...

...who are at low risk for perioperative cardiovascul...

...vasive Coronary Angiography...

...ients undergoing NCS, routine preop...


...ach to Perioperative Cardiac Testing...

...e 1. Stepwise Approach to Perioperative Card...


Management

...nagemen...

.... Cardiovascular Comorbidities and Perioperati...

...Coronary Artery Disease...

...oronary Revascularization...

...ts with ACS being considered for e...

...ith CCD and hemodynamically signifi...

...atients with nonleft main CAD who are planne...

...sion and Perioperative Blood Pressure Managemen...

...rative Blood Pressure Manag...

...In most* patients with HTN planned f...

...tients undergoing elective elevated-ri...

...e Blood Pressure Management...

...undergoing NCS, maintaining an intraoperat...

...rative Blood Pressure Management

...In patients undergoing NCS, treatment of h...

...ents with HTN undergoing NCS, it is recommended...

...Heart Failure...

...tients with HF undergoing elective NCS, sodium-gl...

...In patients with compensated HF undergoing NC...

...8. Association of Heart Failure an...

...ypertrophic Cardiomyopathy...

...ients with hypertrophic cardiomyopathy (HCM...

...Preoperative and Intraoperative Ma...

.... Pulmonary Hypertension...

...tients receiving stable doses of targeted medic...

...n patients with severe† pulmonary hyperten...

...ith severe† PH undergoing elevated...

...nts with precapillary PH undergoing elevated-risk...

...Adult Congenital Heart Disease...

...ith intermediate- to elevated-risk congenital...


...10. ACHD Risk Stratification Before N...


...le 11. ACHD Patient Management for Non...


...t Ventricular Assist Devices...

...patients with a left ventricular assist...


...alvular Heart Disease...


.... Aortic Stenosis...

...ith severe AS should be evaluated for the nee...

...ients with suspected moderate or seve...

...mptomatic patients with moderate or severe A...


...ure 2. Management of Patients With Severe Aortic S...


...Mitral Stenosi...

...Patients with severe mitral stenosis (MS) should...

...with severe MS who cannot undergo MV interve...

...nts with severe MS who cannot unde...


...3. Chronic Aortic and Mitral Regurgitatio...

...ients with suspected moderate or sever...

...tients with VHD who meet indications f...

In asymptomatic patients with moderate or sever...

...ic patients with moderate or severe a...


...ous Transcatheter Aortic Valve Implantation or...

...tients who undergo successful transcatheter a...

...For patients who undergo MV TEER, it is...


...Atrial Fibrillati...

...operative...

...with rapid AF identified in the setting of...

...patients with new-onset AF identified i...

...ost-discharge...

...ients with new-onset AF identified in the...


...6. Cardiovascular Implantable Elec...

...ients with cardiovascular implantable...

...o are pacemaker-dependent having surger...

...aker-dependent patients with a transvenous ICD un...

Patients who have a pacemaker or ICD reprogr...

...with leadless pacemakers who are pacemaker-...

...nts with subcutaneous ICD having noncardiac...


...gure 3. Patients With Transvenous CIEDs...


...nts With Nontransvenous Devices* For patients...


....7. Previous Stroke or Transient Ischemic At...

...In patients with a history of stroke or tra...


...8. Obstructive Sleep Apnea...

...scheduled for NCS, obstructive sleep apn...


...ioperative Medical Therapy...

.... Statins...

...n patients currently on statins and sche...

...¯ve adult patients who meet criteria for stat...

7.2. Renin-Angiotensin-Aldosterone S...

...ect* patients on chronic renin-angiotens...

...In patients on chronic RAASi for H...

...a-2 Receptor Agonists...

...ndergoing NCS, initiation of low-dose...

...let Therapy and Timing of Noncardiac Surgery in P...

...For patients with CAD undergoing elec...

...of NCS After PCI...

...with recent coronary artery balloon angioplasty w...

...with DES-PCI placed for ACS who requ...

...In patients with DES-PCI placed for CCD...

...ients with DES-PCI who require time-sensiti...

...nts with a recent (≤30 days) bare-metal st...

...perative Antiplatelet Management Post PCI...

...ith prior PCI undergoing NCS, it is recommend...

...with CAD who require time-sensitive NCS w...

...with prior PCI in whom OAC monotherapy must be...

...patients after PCI who have a high thrombotic ris...

...Antiplatelet Management in Patients Wit...

...tients with CCD without prior PCI under...

...s with CAD but without prior PCI who ar...

...tion of Antiplatelet Therapy EffectHaving t...

...timal Timing of Elective or Time-Sensitive...

...erioperative Management of Direct Or...

...Oral Anticoagulants...

OAC Management

For patients with CVD receiving...

...AC Bridging

...ts with CVD and high thrombotic risk (T...

...most patients with CVD who are undergoing electiv...

...Resumption...

...nts with preoperative OAC interruption, re...

...able 14. Thromboembolic Risk for Common OAC Ind...

Table 15. Pharmacokinetic Characteristics, Mo...

7.7. Perioperative Beta Blockers

...atients on stable doses of beta blockers...

...scheduled for elective NCS who have a...

...In patients undergoing NCS and with no...

.... Perioperative Management of Blood Gluco...

In patients with or at risk for diabetes who a...

...cheduled for NCS, SGLT2i should be discontinued...

...patients with diabetes or impaired gl...


...sthetic Considerations and Intraoperative Ma...

...Anesthetic Technique and Agent...

...nts undergoing NCS, use of a volatile-...

...In patients undergoing NCS where neura...

...perative Pain Management...

...tients undergoing major abdominal surgery, the us...

...ients with a hip fracture waiting for surgical...

8.3. Intraoperative Monitoring T...

...3.1. Echocardiography

...ith unexplained hemodynamic instabil...

...In patients undergoing NCS without risk facto...

....2. Body Temperatu...

...patients with CVD undergoing NCS, maintenance...

....3.3. Temporary Mechanical Circulator...

...patients with acute, severe hemodynamic inst...

...Pulmonary Artery Catheter...

...n patients with CVD undergoing NCS, the use of P...

In patients with CVD undergoing NCS, ro...

...perative Anemia Management...

...aving NCS with expected blood loss, tranexami...

...s with iron deficiency anemia having elective NCS...


...ative Surveillance and Management of Myocardia...

...rdial Injury After Noncardiac Surgery S...

...Surveillance...

...s with known CVD, symptoms of CVD,...

...patients undergoing low-risk NCS, rou...

...INS Managemen...

...nts who develop MINS, especially in those not...

...patients who develop MINS, antithrombotic...

9.2. Management of Postoperative ST-Segm...

...nts who develop STEMI after NCS shoul...

...ter NCS should receive medical therapy as re...

...ents who develop NSTEMI after NCS can be co...

...igure 6. Evaluation of an Abnormal Tropon...