Perioperative Risk of Noncardiac Surgery
- Devereaux PJ, Sessler DI.
- Cardiac Complications in Patients Undergoing Major Noncardiac Surgery. N Engl J Med 2015;373;2258-2269.
The following are key points to remember from a review article on cardiac complications in patients undergoing major noncardiac surgery:
- Each year, more than 10 million adults worldwide have major cardiac complications in the first 30 days after noncardiac surgery.
- The following are examples of recent preoperative conditions that are independently associated with perioperative cardiac complications: high-risk coronary artery disease (e.g., myocardial infarction or Canadian Cardiovascular Society class III or IV angina within 6 months before surgery), stroke within 3 months before surgery, and coronary artery stenting within 6 months before surgery.
- Surgery and anesthesia are associated with activation of the sympathetic nervous system, inflammation, hypercoagulability, hemodynamic compromise, bleeding, and hypothermia, all of which are associated with cardiac complications.
- There are two preoperative cardiac risk indexes that may assist in the preoperative prediction of cardiac complications. The best-validated risk model is the Revised Cardiac Risk Index (RCRI); however, it does not inform risk among patients undergoing emergency surgery and original risk estimates are 50% lower than the rates of events observed in more recent cohort studies.
- The National Surgical Quality Improvement Program risk index for Myocardial Infarction and Cardiac Arrest (NSQIP MICA) has been shown to have a predictive performance that exceeds that of the RCRI.
- Preoperative cardiac stress testing is recommended in patients with limited functional capacity who, on the basis of clinical factors, are considered to have a risk of a major cardiac event of 1% or more and in whom the test result would influence treatment.
- An elevated preoperative plasma level of B-type natriuretic peptide (BNP) is a particularly strong independent predictor of adverse preoperative outcomes.
- In patients with stable coronary artery disease, there are no data to support preoperative coronary revascularization.
- Models of shared care between surgeons and internists may improve outcomes for patients.
- Most myocardial infarctions occur within 48 hours of noncardiac surgery, when patients are receiving analgesic medications that can mask symptoms of ischemia.
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