Perioperative Cardiovascular Care | Ten Points to Remember

Authors:
Eagle KA, Vaishnava P, Froehlich JB.
Citation:
Perioperative Cardiovascular Care for Patients Undergoing Noncardiac Surgical Intervention. JAMA Intern Med 2015;Mar 16:[Epub ahead of print].

The following are 10 points to remember about perioperative cardiovascular care for patients undergoing noncardiac surgical intervention:

  1. The field of perioperative medicine has obtained importance in recent years since adverse cardiovascular events in the perioperative period account for significant morbidity and mortality.
  2. Current guidelines recommend preoperative noninvasive stress testing only in patients deemed to be at escalated risk and for whom the results of such testing would modify perioperative care or further decision making.
  3. Validated risk stratification tools, such as the Revised Cardiac Risk Index or the National Surgical Quality Improvement Program risk calculator, can assist in the identification of patients for whom preoperative noninvasive testing is justified and may change the management.
  4. Current guidelines recommend that prophylactic coronary revascularization should not be performed exclusively for the purposes of reducing the risk of perioperative events.
  5. It has been shown in randomized studies that routine coronary revascularization prior to noncardiac operations does not reduce perioperative cardiac events.
  6. The lack of benefit from prophylactic coronary revascularization has taught us to not rely on unproven hypotheses (e.g., fixed coronary stenoses are the predominant mechanism of adverse perioperative outcomes).
  7. It is clear that long-term beta-blockade therapy should not be interrupted or stopped abruptly in the perioperative period, as it may produce withdrawal effects.
  8. It is also clear that if beta-blockade is initiated perioperatively, it should be done thoughtfully and well in advance of the surgical procedure.
  9. Clinicians should resist the temptation to use therapy simply because it is physiologically intuitive, without the benefit of high-quality data free of major limitations.
  10. Clinicians need to initiate therapies carefully, for the purpose of accruing long-term benefit in patients undergoing noncardiac surgery.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention

Keywords: Perioperative Care, Perioperative Period, Coronary Stenosis, Quality Improvement, Risk, Mortality, Morbidity, Myocardial Ischemia, Vascular Surgical Procedures, Secondary Prevention


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