Perioperative CV Risk Assessment for Noncardiac Surgery

Quick Takes

  • Preoperative risk assessment decisions should be informed by focused history, physical examination, assessment of functional limitations, and complexity of the planned surgical procedure.
  • Available assessment tools distinguish patients at low (<1%) versus high (≥1%) risk for 30-day postoperative MACE.
  • Cardiovascular testing is rarely indicated in low-risk patients, or in those able to perform ≥4 METs of exercise; routine referral for preoperative revascularization does not improve postoperative outcome and is not recommended.
  • Patients with coronary stents warrant additional consideration, including detailed risk assessment and participation of the patient’s cardiologist in perioperative decision making.

Study Questions:

Can aggregate findings from relevant, up-to-date published literature, combined with use of available risk assessment tools, inform a systematic approach to preoperative risk assessment and risk reduction?

Methods:

Search of the MEDLINE database and the Cochrane Library for publications on perioperative cardiovascular risk assessment and risk reduction, submitted between January 1, 1949 and January 27, 2020, was performed. Publications were selected based on consensus of their clinical relevance. Data supporting various approaches to preoperative testing (including functional exercise testing, assessment of myocardial ischemia, echocardiography, biomarker measurement, and coronary angiography) interventions (including revascularization, anticoagulation/antiplatelet medication management, or use of specialty consultation), and special populations (older age, in situ coronary stents, and planned emergency procedures) were reviewed.

Results:

The authors summarize the evidence supporting various practices, including recent large observational trials, and contribute their own recommendations on selected topics. Recommendations from existing consensus guidelines are often compared, and special surgical populations at greater risk of adverse postoperative outcomes are emphasized. The authors cite advantages of individualizing preoperative testing. For example, with the exception of specific conditions including known moderate-severe valvular heart disease with unstable symptoms, suspected hypertrophic cardiomyopathy with risk of dynamic outflow tract obstruction, or planned solid organ transplant, routine use of echocardiography for evaluation of left ventricular function is not recommended.

A proposed algorithm for preoperative assessment is depicted, based on emergent versus nonemergent nature of planned surgery, presence of severe unstable conditions (arrhythmias, severe valvular heart disease, acute heart failure, or acute coronary syndrome [ACS]), previous coronary stenting, and computed risk of perioperative major adverse cardiac events (MACE) according to one of several available online risk calculators. A patient with ≥1% risk of postoperative MACE, based on output from a risk calculator, may proceed to surgery if on optimum medical management and if able to perform ≥4 METs. Patients at ≥1% MACE risk and inability to perform ≥4 METs should only undergo further testing if the results might alter decision making or aspects of the planned perioperative care.

Despite meta-analysis-level data showing significant association between coronary computed tomographic angiography (CCTA) findings and risk of postoperative MACE, CCTA is not currently recommended for preoperative risk stratification. Routine preoperative coronary revascularization is not recommended by the current American College of Cardiology/American Heart Association consensus guidelines, or by these authors, despite the known relationship between coronary disease and postoperative MACE.

Consultation with a cardiologist is recommended in patients with coronary stents, or with abnormal noninvasive stress test results. Factors contributing to postoperative risk in patients with coronary stents include: 1) stent-specific factors (time preceding stent placement [<3, <6, 6-12 or >12 months], stent type [drug-eluting versus bare metal], length of the coronary lesion and stent [longer vs. shorter], and indication for the stent [ACS vs. stable coronary artery disease]), 2) disadvantageous patient factors (age ≥60 years, heart failure, glomerular filtration rate <30 ml/min, and Hg <10 g/dl), and 3) surgical considerations (high procedural risk, high bleeding risk, and urgent/emergent status). Issues that should be addressed during consultation include appropriate timing of surgery, continuation of aspirin when feasible, optimization of lipid-lowering therapy, and strategies to minimize hemodynamic instability.

Postoperative troponin surveillance was deemed reasonable for patients with Revised Cardiac Risk Index >1 during the first 48 hours after surgery, if results would alter clinical management.

Conclusions:

A simple, stepwise approach to preoperative assessment and perioperative management is presented that includes acknowledgement of surgical urgency, exclusion of acute unstable conditions, special considerations of patients with coronary stents, dichotomous risk stratification, and an estimate of functional capacity.

Perspective:

Although this preoperative assessment algorithm has not been tested prospectively, it is conceptually simple and its components are well-supported by available clinical evidence. Questions warranting further research include optimum management of older patients, who have been under-represented in clinical studies, and possible value of preoperative optimization based on natriuretic peptide measurements.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, ACS and Cardiac Biomarkers, Anticoagulation Management and ACS, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Anticoagulants, Biological Markers, Coronary Angiography, Diagnostic Imaging, Echocardiography, Exercise Test, Heart Failure, Heart Valve Diseases, Myocardial Ischemia, Myocardial Revascularization, Perioperative Care, Primary Prevention, Risk Assessment, Risk Reduction Behavior, Stents, Surgical Procedures, Elective, Tomography, X-Ray Computed, Troponin


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