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
...itions and Calculators
...The numbering of the following tables...
...Definitions of Surgical Timing and S...
3. Risk Calcu...
....1. Cardiovascular Risk Indices In patients with...
...ores and CalculatorsHaving trouble viewing table...
Assessment
Assessment
...2 Functional Capacity Assessment In patients...
...ctivity Status Index (DASI)Having trouble vi...
...lty In all patients ≥65 years of age a...
...railty Assessment ToolsHaving trouble viewing...
...tive Biomarkers for Risk Stratificat...
...ients with known CVD, or age ≥65 years,...
...with known CVD, or age ≥65 years,...
.... Preoperative Cardiovascular Diagnostic Tes...
...2-Lead Electrocardiogram
...For patients with known coronary heart dise...
In patients undergoing NCS with a preoperat...
...For asymptomatic patients undergoing elevat...
...For asymptomatic patients undergoi...
...nt of Ventricular Function...
...eft Ventricular Function...
...atients undergoing NCS with new dyspnea, p...
...ents with a known diagnosis of HF wit...
...In asymptomatic and clinically stable patients u...
....3. Stress Te...
...r patients undergoing elevated-risk NCS with poor...
...ients who are at low risk for perioperative car...
4.3.1. Modality Selection for Stre...
...Considerations and Contraindications for Spec...
4.5. Coronary Computed Tomography Angio...
...r patients undergoing elevated-risk surgery with p...
...who are at low risk for perioperative cardiova...
...ve Coronary Angiography
...n patients undergoing NCS, routine preoper...
...Approach to Perioperative Cardiac Testing...
...e 1. Stepwise Approach to Perioperative Cardi...
Management
Managem...
...ar Comorbidities and Perioperative Manageme...
...Coronary Artery Disease
....1.1. Coronary Revascularization
...n patients with ACS being considere...
...with CCD and hemodynamically significa...
...tients with nonleft main CAD who are pl...
...tension and Perioperative Blood Pressure M...
...tive Blood Pressure Management...
In most* patients with HTN plan...
...atients undergoing elective elevated-risk surge...
...tive Blood Pressure Management...
...ents undergoing NCS, maintaining an intr...
...stoperative Blood Pressure Mana...
In patients undergoing NCS, treatmen...
...atients with HTN undergoing NCS, it i...
6.3. Heart Failu...
...ents with HF undergoing elective NC...
...In patients with compensated HF undergoing NCS, i...
...Association of Heart Failure and Left Vent...
...rtrophic Cardiomyopathy...
...with hypertrophic cardiomyopathy (HCM)...
...eoperative and Intraoperative Management Con...
...ulmonary Hypertension...
...receiving stable doses of targeted medica...
...s with severe† pulmonary hypertension (PH)...
...with severe† PH undergoing elevated-ris...
...s with precapillary PH undergoing elevat...
....3. Adult Congenital Heart Dis...
...In patients with intermediate- to elevated-...
...10. ACHD Risk Stratification Before Noncar...
...CHD Patient Management for Noncardiac SurgeryClar...
....3.4. Left Ventricular Assist...
...atients with a left ventricular ass...
...Valvular Heart Disease...
6.4.1. Aortic Stenos...
...th severe AS should be evaluated fo...
...ith suspected moderate or severe AS who...
...In asymptomatic patients with moderate...
.... Management of Patients With Severe Aor...
...4.2. Mitral Ste...
...ents with severe mitral stenosis (MS) s...
...patients with severe MS who cannot undergo MV in...
...patients with severe MS who cannot undergo MV int...
....4.3. Chronic Aortic and Mitral Regurgitation
...ts with suspected moderate or severe valvula...
...In patients with VHD who meet indicat...
...symptomatic patients with moderate or severe M...
...In asymptomatic patients with moder...
....4. Previous Transcatheter Aortic...
...who undergo successful transcatheter aortic val...
...ients who undergo MV TEER, it is reasona...
...Atrial Fibrillation
...rioperative
...s with rapid AF identified in the setting of NCS...
...with new-onset AF identified in the sett...
Post-disch...
...with new-onset AF identified in the setting...
...scular Implantable Electronic Devices...
...with cardiovascular implantable electroni...
...Patients who are pacemaker-dependent having surg...
...dependent patients with a transvenous ICD und...
...Patients who have a pacemaker or ICD...
...Patients with leadless pacemakers...
...tients with subcutaneous ICD having noncardiac or...
...ients With Transvenous CIEDs* EMI is consider...
...4. Patients With Nontransvenous Devices* F...
...s Stroke or Transient Ischemic Attack
...ts with a history of stroke or transient ischemi...
...structive Sleep Apnea...
...ients scheduled for NCS, obstructive slee...
...perative Medical Therapy
....1. Stati...
...nts currently on statins and scheduled f...
...aïve adult patients who meet criteri...
...iotensin-Aldosterone System Inhibitors...
...ect* patients on chronic renin-angiote...
...ts on chronic RAASi for HFrEF, perioperative...
7.4. Alpha-2 Recepto...
...In patients undergoing NCS, initiation of...
...elet Therapy and Timing of Noncardiac Su...
...atients with CAD undergoing electi...
...g of NCS After PCI...
...ients with recent coronary artery balloon angi...
...ients with DES-PCI placed for ACS who require e...
...In patients with DES-PCI placed for CCD wh...
In patients with DES-PCI who require time-s...
...In patients with a recent (≤30 days) bare-meta...
...rioperative Antiplatelet Management Pos...
...In patients with prior PCI undergoing NCS, it...
...nts with CAD who require time-sensitive N...
...In patients with prior PCI in whom OAC monothera...
...In select patients after PCI who have...
...ve Antiplatelet Management in Patients Wit...
...ients with CCD without prior PCI undergoing electi...
...ients with CAD but without prior PCI who ar...
.... Duration of Antiplatelet Therapy...
...Optimal Timing of Elective or Time-Sen...
...13. Perioperative Management of Direct Oral...
...Oral Anticoagulants
...Management...
...with CVD receiving OAC who require...
OAC Bridgi...
...patients with CVD and high thrombotic risk...
...most patients with CVD who are underg...
OAC Resump...
In patients with preoperative OAC in...
...able 14. Thromboembolic Risk for Common...
...rmacokinetic Characteristics, Monitor...
...operative Beta Blockers...
...In patients on stable doses of beta blocker...
...scheduled for elective NCS who have a new indi...
...ients undergoing NCS and with no imm...
...ive Management of Blood Glucose...
...with or at risk for diabetes who are...
...nts scheduled for NCS, SGLT2i should be di...
...In patients with diabetes or impaired glucos...
...ic Considerations and Intraoperative Managem...
...oice of Anesthetic Technique and...
...patients undergoing NCS, use of a volat...
...ndergoing NCS where neuraxial is feasib...
...rioperative Pain Management...
...undergoing major abdominal surgery, the use...
For patients with a hip fracture waiting for...
...aoperative Monitoring Techniques...
.... Echocardiography...
...with unexplained hemodynamic instability u...
...ndergoing NCS without risk factors or procedu...
.... Body Temperature...
...with CVD undergoing NCS, maintenance of normoth...
8.3.3. Temporary Mechanical Circulatory Supp...
...ients with acute, severe hemodynamic instabili...
...monary Artery Catheters...
...tients with CVD undergoing NCS, the us...
...patients with CVD undergoing NCS,...
...4. Perioperative Anemia Mana...
...ents having NCS with expected blood los...
...ents with iron deficiency anemia hav...
...ative Surveillance and Management o...
...Myocardial Injury After Noncardiac Surg...
...S Surveillance...
...In patients with known CVD, symptoms of...
...ents undergoing low-risk NCS, routine pos...
...NS Management...
...ho develop MINS, especially in those n...
...nts who develop MINS, antithrombotic...
...nt of Postoperative ST-Segment-Elevation Myocar...
...Patients who develop STEMI after NCS should...
...NCS should receive medical therapy...
...ts who develop NSTEMI after NCS can be co...
...valuation of an Abnormal Troponin Obtaine...