Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
Overview
Overview
Top Take-Home Messages
- A stepwise approach to perioperative cardiac assessment assists clinicians in determining when surgery should proceed or when a pause for further evaluation is warranted.
- 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.
- 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.
- Team-based care should be emphasized when managing patients with complex anatomy or unstable cardiovascular disease.
- 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.
- Myocardial injury after NCS is a newly identified disease process that should not be ignored because it portends real consequences for affected patients.
- 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.
- 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.
- 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
...initions and Calculato...
Note: The numbering of the following ta...
...efinitions of Surgical Timing and...
.... Risk Calcul...
...Cardiovascular Risk Indices In patients with...
...cores and CalculatorsHaving trouble viewing...
Assessment
Assessm...
...onal Capacity Assessment In patient...
...ble 5. Duke Activity Status Index (DA...
...ilty In all patients ≥65 years of age and...
...ilty Assessment ToolsHaving trouble viewing tabl...
...ive Biomarkers for Risk Stratification...
...patients with known CVD, or age ≥65 ye...
...In patients with known CVD, or age ≥6...
...Preoperative Cardiovascular Diagnosti...
...-Lead Electrocardiogram
...For patients with known coronary heart disea...
...ts undergoing NCS with a preoperative ECG ex...
...tomatic patients undergoing elevated-risk surg...
...or asymptomatic patients undergoing low-ris...
...ment of Ventricular Function...
4.2.1. Left Ventricular...
...ents undergoing NCS with new dyspnea, physi...
...In patients with a known diagnosis of HF with...
...mptomatic and clinically stable pat...
.... Stress Testing...
...ents undergoing elevated-risk NCS with p...
...In patients who are at low risk for perioperat...
...ty Selection for Stress Testing...
...siderations and Contraindications for Speci...
...Computed Tomography Angiography...
...tients undergoing elevated-risk surgery w...
...atients who are at low risk for periopera...
...6. Invasive Coronary Angiogra...
...nts undergoing NCS, routine preoperativ...
...proach to Perioperative Cardiac Te...
...epwise Approach to Perioperative Cardiac...
Management
...agement...
...Cardiovascular Comorbidities and...
...Coronary Artery Diseas...
...1. Coronary Revascularization...
...s with ACS being considered for elective NCS, cor...
...ith CCD and hemodynamically significant...
...tients with nonleft main CAD who are planned...
...rtension and Perioperative Blood Pres...
...perative Blood Pressure Management...
...ients with HTN planned for elective NCS, it...
...In patients undergoing elective elevate...
...ive Blood Pressure Management...
...nts undergoing NCS, maintaining an intra...
...e Blood Pressure Management...
...undergoing NCS, treatment of hypotensi...
...In patients with HTN undergoing NCS, it is recomm...
...eart Failure...
...In patients with HF undergoing elective NCS,...
...nts with compensated HF undergoing NCS,...
Table 8. Association of Heart Failure...
...3.1. Hypertrophic Cardio...
...For patients with hypertrophic car...
...9. Preoperative and Intraoperative Management C...
...lmonary Hypertension...
...In patients receiving stable doses of ta...
...nts with severe†pulmonary hypertension (PH...
...In patients with severe†PH undergoi...
...ients with precapillary PH undergoing elev...
...3.3. Adult Congenital Heart Disease...
...atients with intermediate- to elevated-ris...
...10. ACHD Risk Stratification Before Noncardiac...
...ble 11. ACHD Patient Management for Noncar...
...Left Ventricular Assist Devi...
...patients with a left ventricular assist devi...
...4. Valvular Heart Dise...
...1. Aortic Stenosis
...tients with severe AS should be evaluate...
...ients with suspected moderate or severe A...
...ymptomatic patients with moderate or...
...gure 2. Management of Patients With...
...4.2. Mitral Stenosis
...with severe mitral stenosis (MS) should be eva...
...with severe MS who cannot undergo MV intervent...
...patients with severe MS who cannot u...
...ic Aortic and Mitral Regurgitation...
...atients with suspected moderate or severe valvu...
...patients with VHD who meet indications fo...
...tomatic patients with moderate or seve...
...In asymptomatic patients with moderate or se...
...Previous Transcatheter Aortic Valve Implantati...
...atients who undergo successful transc...
...nts who undergo MV TEER, it is reasonab...
6.5. Atrial Fibrillat...
...operative...
...s with rapid AF identified in the setting of NC...
...In patients with new-onset AF identified...
...ost-discharge...
...ients with new-onset AF identified in the se...
...vascular Implantable Electronic Devices...
...h cardiovascular implantable electronic devic...
...nts who are pacemaker-dependent hav...
...-dependent patients with a transvenous ICD un...
...have a pacemaker or ICD reprogrammed...
...with leadless pacemakers who are pacemaker-dep...
...ents with subcutaneous ICD having noncard...
...Patients With Transvenous CIEDs* EMI...
...Patients With Nontransvenous Devices* For...
...ous Stroke or Transient Ischemic Attack...
...patients with a history of stroke or transie...
...8. Obstructive Sleep...
...In patients scheduled for NCS, obstruct...
...perative Medical Therapy...
....1. Statins
...ients currently on statins and scheduled f...
...in-naïve adult patients who meet cri...
...2. Renin-Angiotensin-Aldosterone System Inh...
In select* patients on chronic r...
...In patients on chronic RAASi for HFrEF,...
...Alpha-2 Receptor Agonists...
...ients undergoing NCS, initiation of low...
.... Antiplatelet Therapy and Timing of Noncardiac Su...
...For patients with CAD undergoing elective NCS,...
...ing of NCS After PCI
...ents with recent coronary artery b...
...patients with DES-PCI placed for ACS who req...
...ts with DES-PCI placed for CCD who require...
...patients with DES-PCI who require time-...
...ts with a recent (≤30 days) bare-met...
...rative Antiplatelet Management Post PCI...
...patients with prior PCI undergoing NCS,...
...ients with CAD who require time-sensitive NCS...
...In patients with prior PCI in whom OAC...
...ct patients after PCI who have a high thromb...
...rioperative Antiplatelet Management in Pa...
...s with CCD without prior PCI undergoing elec...
...ts with CAD but without prior PCI...
...2. Duration of Antiplatelet Therapy EffectH...
...re 5. Optimal Timing of Elective or Time...
...erative Management of Direct Oral Anticoagulan...
...6. Oral Anticoagulants...
OAC Manageme...
...or patients with CVD receiving OAC who...
...AC Bridging...
...ith CVD and high thrombotic risk (Table 14) und...
...most patients with CVD who are undergo...
OAC Resumptio...
...ients with preoperative OAC interrupt...
...oembolic Risk for Common OAC IndicationsHaving...
.... Pharmacokinetic Characteristics, Monitorin...
....7. Perioperative Beta Blo...
...on stable doses of beta blockers undergoing...
...ients scheduled for elective NCS w...
...ndergoing NCS and with no immediate need for beta...
....8. Perioperative Management of B...
...with or at risk for diabetes who are scheduled...
...nts scheduled for NCS, SGLT2i should be disco...
...atients with diabetes or impaired glucose to...
...c Considerations and Intraoperativ...
....1. Choice of Anesthetic Techni...
...patients undergoing NCS, use of a volatil...
...n patients undergoing NCS where neura...
...Perioperative Pain Manag...
...patients undergoing major abdominal sur...
...ients with a hip fracture waiting for surgica...
...Intraoperative Monitoring T...
....3.1. Echocardiogra...
...with unexplained hemodynamic instability undergo...
...n patients undergoing NCS without risk...
....3.2. Body Temperat...
...ients with CVD undergoing NCS, mainte...
...y Mechanical Circulatory Support...
...ents with acute, severe hemodynamic instability...
...onary Artery Catheters...
...atients with CVD undergoing NCS, the use of PA ca...
...In patients with CVD undergoing NCS, routine...
...rioperative Anemia Management...
...having NCS with expected blood loss, tr...
...patients with iron deficiency anemia having el...
...ve Surveillance and Management of Myocardial Inju...
...ocardial Injury After Noncardiac Surgery Sur...
...Surveillance...
...n patients with known CVD, symptoms of CVD, or...
...ndergoing low-risk NCS, routine post...
...INS Management
...ients who develop MINS, especially...
...who develop MINS, antithrombotic t...
...of Postoperative ST-Segment-Elevation Myocardial I...
...ts who develop STEMI after NCS shou...
...after NCS should receive medical...
...ho develop NSTEMI after NCS can be con...
...luation of an Abnormal Troponin Obtained for Post...