Perspective:

The following are 10 points to remember about clinical practice guidelines for the perioperative cardiovascular evaluation and management of the adult patient undergoing noncardiac surgery:

1. The aims of preoperative evaluation in the patient undergoing noncardiac surgery are: 1) Assessment of perioperative risk to guide the decision to proceed with or the choice of surgery, 2) determination of the need for changes in management, and 3) identification of cardiovascular conditions or risk factors that warrant longer-term management.

2. The cornerstone of perioperative evaluation is a collaborative “perioperative team approach” that relies on communication between all relevant parties (i.e., surgeon, anesthesiologist, primary caregiver, and consultants). Such partnership should involve the patient, incorporate his/her preferences and goals, and facilitate shared decision making.

3. Although previous risk stratification schema have included low-, intermediate-, and high-risk classifications to characterize the risk of surgery, the guideline writing committee has simplified this categorization to low-risk (where the risk of major adverse cardiac events is <1%) or elevated risk (where this risk is ≥1%).

4. For patients who are at an elevated risk for noncardiac surgery (as determined by a validated risk prediction tool capable of predicting the risk of perioperative major adverse cardiovascular events including the NSQIP Risk Calculator), noninvasive pharmacologic stress testing is indicated if it will impact further decision making OR perioperative care (Class IIa, Level of Evidence: B).

5. Elevated risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in the following patients: asymptomatic severe aortic stenosis (Class IIa, Level of Evidence: B), asymptomatic severe mitral regurgitation (Class IIa, Level of Evidence: C), asymptomatic severe aortic regurgitation with a normal left ventricular ejection fraction (Class IIa, Level of Evidence: C), and asymptomatic severe mitral stenosis if valve morphology is not favorable for percutaneous mitral balloon commissurotomy (Class IIb, Level of Evidence: C).

6. Although the PARTNER (Placement of Aortic Transcatheter Valves) randomized controlled trial demonstrated that transcatheter aortic valve replacement (TAVR) has superior outcomes for patients ineligible for surgical AVR, and similar efficacy for those who are at high risk, there are no data for the efficacy or safety of TAVR for patients with aortic stenosis undergoing noncardiac surgery.

7. As there are emerging data to suggest that the risk of stent thrombosis in the newer-generation drug-eluting stents stabilizes after 6 months, elective noncardiac surgery after drug-eluting stent implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis (Class IIb, Level of Evidence: B).

8. In patients who have received coronary stents and must undergo surgical procedures that mandate the discontinuation of P2Y₁₂ platelet receptor inhibitor therapy, it is recommended to continue aspirin if possible and restart the P2Y₁₂ platelet receptor inhibitor as soon as possible after surgery (Class I, Level of Evidence: C). Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient weighing the relative risk of bleeding versus prevention of stent thrombosis (Class I, Level of Evidence: C).

9. 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 (Class I, Level of Evidence: B). Abrupt withdrawal from long-term beta-blocker therapy may be harmful.

10. Initiation of beta-blocker therapy perioperatively is reasonable in patients with intermediate- or high-risk myocardial ischemia noted in preoperative risk stratification (Class IIb, Level of Evidence: C), or those with three or more Revised Cardiac Risk Index factors (Class IIb, Level of Evidence: B) based upon an independent evidence review which took into account the controversy regarding the evidence. Although beta-blocker therapy should not be started on the day of surgery in beta-blocker naïve patients (Class III), there are paucity of data to support initiation >30 days beforehand. It is prudent to initiate beta-blocker therapy in beta-blocker naïve patients 2-7 days before surgery; optimal dosing and titration perioperatively, although not yet defined, are important to avoid hemodynamic instability from hypotension and/or bradycardia.