- 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., ACS NSQIP 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.
Table 1. Definitions of Urgency and Risk
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.||IIa||B|
|For patients with a low risk of perioperative MACE, further testing is NOT recommended before the planned operation.||III: No Benefit||B|
|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.||IIa||B|
|Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery.||IIb||B|
|Routine preoperative resting 12-lead ECG is NOT useful for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery.||III: No Benefit||B|
|Assessment of LV function|
|It is reasonable for patients with dyspnea of unknown origin to undergo preoperative evaluation of LV function.||IIa||C|
|It is reasonable for patients with HF with worsening dyspnea or other change in clinical status to undergo preoperative evaluation of LV function.||IIa||C|
|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.||IIb||C|
|Routine preoperative evaluation of LV function is NOT recommended.||III: No Benefit||B|
|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.||IIa||B|
|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.||IIb||B|
|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.||IIb||B|
|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.||IIb||C|
|Routine screening with noninvasive stress testing is NOT useful for patients at low-risk for noncardiac surgery.||III: No Benefit||B|
|Cardiopulmonary exercise testing|
|Cardiopulmonary exercise testing may be considered for patients undergoing elevated risk procedures in whom functional capacity is unknown.||IIb||B|
|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.||IIa||B|
|Routine screening with noninvasive stress testing is NOT useful for patients undergoing low-risk noncardiac surgery.||III: No Benefit||B|
|Preoperative coronary angiography|
|Routine preoperative coronary angiography is NOT recommended.||III: No Benefit||C|
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.||I||C|
|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.||I||C|
|Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis.||IIa||B|
|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.||IIb||C|
|Aortic and Mitral Regurgitation|
|Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe MR.||IIa||C|
|Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe AR and a normal LVEF.||IIa||C|
|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.||I||C|
|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.||I||C|
|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.||I||C|
|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||IIa||C|
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.