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

...Dia...

...tions of Urgency and Risk...


...wise Approach to Perioperative Cardiac As...


...Table 2. Supplem...

...risk-prediction tool can be useful i...

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

...The 12-lead ECG...

Preoperative resting 12-lead ECG is reasonable...

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

...eoperative resting 12-lead ECG is NOT useful...

...Assessment of LV...

...e for patients with dyspnea of unkno...

...easonable for patients with HF with worsening...

...LV function in clinically stable patien...

...outine preoperative evaluation of LV...

...Ex...

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

...tients with elevated risk and unknown functional...

...nts with elevated risk and moderate to good (...

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

...ning with noninvasive stress testing i...

...Cardiopulmonary exercise t...

...ardiopulmonary exercise testing may be consi...

...Noninvasive pharm...

...sonable for patients who are at elevated...

...ng with noninvasive stress testing is...

...Preoperative...

...perative coronary angiography is NOT recomm...


...Tab...

...Val...

...s recommended that patients with clinically s...

...meet standard indications for valvular inter...

...Aort...

...lective noncardiac surgery with app...

...Mitral...

...lective noncardiac surgery using appropriate i...

...Aortic and M...

...d-risk elective noncardiac surgery with appropriat...

...ated-risk elective noncardiac surgery with app...

...CIEDs...

Before elective surgery in a patient with a...

...th ICDs who have preoperative reprog...

...Pulmonary...

...pulmonary vascular targeted therapy (i.e...

...of delay outweigh the potential benefits, preope...


Treatment

...Treatmen...

...Table 4. Peri...

...Coronary revasculariza...

...rization before noncardiac surgery is rec...

...t is NOT recommended that routine cor...

...Timi...

...ys after balloon angioplasty ( C , I )...

...ys after BMS implantation ( B , I )701...

...noncardiac surgery should optimally be delayed...

...ents in whom noncardiac surgery is r...

...iac surgery after DES implantation ma...

...ve noncardiac surgery should NOT be p...

...iac surgery should NOT be performed with...

...Perio...

...ckers should be continued in patients undergoing...

...nable for the management of beta block...

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

...nts with ≥3 RCRI risk factors (e.g.,...

...tients with a compelling long-term...

...ients in whom beta-blocker therapy i...

...ker therapy should NOT be started on the day of s...

...Perioperati...

...ins should be continued in patients current...

...perative initiation of statin use is reaso...

...nitiation of statins may be considered in...

...Alpha-2 ago...

...ists for prevention of cardiac events are NOT r...

...ACE i...

...uation of ACE inhibitors or ARBs periopera...

...s or ARBs are held before surgery, it is reasona...

...Antiplatelet agents...

...patients undergoing urgent noncardiac sur...

...nts who have received coronary stents and mus...

...ent of the perioperative antiplate...

...atients undergoing nonemergency/nonurgent nonc...

...01...

...risk of ischemic events outweighs risk of surgical...

...se of new evidence, this is a new recomm...


...orithm for Antiplatelet Management in Patients...


...Table 5. Anesthe...

...Volatile genera...

...of either a volatile anesthetic agent or to...

...Perioperative p...

...raxial anesthesia for postoperative pain reli...

...ve epidural analgesia may be consid...

...travenous nitroglycerin is NOT effective in red...

...Intraoperative monitor...

...gency use of perioperative TEE is re...

Routine use of intraoperative TEE during nonca...

...Maintenance of body temper...

...tenance of normothermia may be reasonabl...

...Hemodynamic as...

...e of hemodynamic assist devices may be co...

...Perioperative...

...se of pulmonary artery catheterization may...

...tine use of pulmonary artery catheterization in...


...Table 6. Surv...

...t of troponin levels is recommended in t...

...ning an ECG is recommended in the set...

...usefulness of postoperative screening with tropo...

...usefulness of postoperative screening w...

...ne postoperative screening with troponi...