Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
Key Points
Key Points
- 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., ACSNSQIP 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.
Diagnosis
...agnosis
...le 1. Definitions of Urgency and RiskHaving...
...re 1. Stepwise Approach to Perioperative...
...lemental Preoperative Evaluation...
...iate Risk Indices
A validated risk-prediction tool can be...
...ts with a low risk of perioperative...
...12-lead ECG...
...ting 12-lead ECG is reasonable for pati...
...eoperative resting 12-lead ECG may b...
...ine preoperative resting 12-lead EC...
...nt of LV function...
...nable for patients with dyspnea of un...
...nable for patients with HF with worseni...
...t of LV function in clinically stable patient...
...e preoperative evaluation of LV func...
...tress testing for myocardial ischemia and function...
...ents with elevated risk and excellent (>10 METs)...
...atients with elevated risk and unknown func...
...ith elevated risk and moderate to goo...
...s with elevated risk and poor or unknow...
...ning with noninvasive stress testing is...
...monary exercise testin...
...lmonary exercise testing may be cons...
...macological stress testing before noncardiac...
...reasonable for patients who are at el...
...ne screening with noninvasive stress testing i...
...reoperative coronary angi...
...tine preoperative coronary angiogr...
...lar Heart Disease, CIEDs and Pulmonary Vascular...
...vular Heart Disease...
It is recommended that patients with clinically su...
...ho meet standard indications for val...
...tic Stenosis...
...vated-risk elective noncardiac surgery with...
...l Stenosis...
...ted-risk elective noncardiac surgery us...
...and Mitral Regurgitation...
...ed-risk elective noncardiac surgery with appropr...
...d-risk elective noncardiac surgery with appr...
CIED...
...surgery in a patient with a CIED, the s...
...ts with ICDs who have preoperative...
...monary Vascular Di...
...c pulmonary vascular targeted thera...
...s the risks of delay outweigh the pot...
Treatment
...eatmen...
...Perioperative Therapy...
...ry revascularization before noncardiac surgery...
...evascularization before noncardiac surgery...
...ommended that routine coronary revasc...
...ng of elective noncardiac surgery in...
...s after balloon angioplasty ( C , I )701...
...ter BMS implantation ( B , I )701...
...noncardiac surgery should optimally be d...
...ents in whom noncardiac surgery is required,...
...ective noncardiac surgery after DES implanta...
...iac surgery should NOT be performed within 30...
...tive noncardiac surgery should NOT be...
...ive beta-blocker therapy...
...a blockers should be continued in pa...
...t is reasonable for the management of beta block...
...with intermediate- or high-risk myocardial...
...with ≥3 RCRI risk factors (e.g., diab...
...ents with a compelling long-term indica...
...n patients in whom beta-blocker therapy is initiat...
...ta-blocker therapy should NOT be s...
...ative statin therapy...
...hould be continued in patients currently ta...
...e initiation of statin use is reasonable in pati...
...e initiation of statins may be considered...
...pha-2 agonists...
Alpha-2 agonists for prevention of car...
...E inhibitor...
...of ACE inhibitors or ARBs perioperativel...
...bitors or ARBs are held before surgery, it...
...atelet agents...
Continue DAPT in patients undergoing...
...ts who have received coronary stents and m...
...f the perioperative antiplatelet thera...
...undergoing nonemergency/nonurgent noncardiac s...
...01...
...risk of ischemic events outweighs risk o...
...Because of new evidence, this is a new...
Figure 2. Algorithm for Antiplatelet Mana...
...e 5. Anesthetic Consideration and Intraoperat...
...al anesthesia versus total intravenous anesthesi...
...a volatile anesthetic agent or total intra...
...operative pain managemen...
...euraxial anesthesia for postoperativ...
...reoperative epidural analgesia may be con...
...c intraoperative nitroglycerin...
...rophylactic intravenous nitroglycerin is NOT effec...
...rative monitoring techniq...
...e of perioperative TEE is reasonable...
...intraoperative TEE during noncardiac surgery to s...
...tenance of body tempe...
...ce of normothermia may be reasonable to reduc...
...namic assist devic...
...hemodynamic assist devices may be considered whe...
...erative use of pulmonary artery catheters...
...e use of pulmonary artery catheteriz...
...ne use of pulmonary artery catheteriza...
...lance and Management for Perioperative MI...
...ment of troponin levels is recommended in the set...
...is recommended in the setting of signs or sympto...
...f postoperative screening with troponin levels in...
...ness of postoperative screening with ECGs...
...rative screening with troponin levels in unselec...