Cardiac Risk of Noncardiac Surgery

Patel AY, Eagle KA, Vaishnava P.
Cardiac Risk of Noncardiac Surgery. J Am Coll Cardiol 2015;66:2140-2148.

The following are 10 key points to remember from this review on cardiac risk of noncardiac surgery:

  1. Major perioperative cardiac events are estimated to complicate between 1.4% and 3.9% of surgeries.
  2. Because most surgeries are elective, there is the opportunity to implement strategies to reduce this risk.
  3. Accurate identification of patients at risk for such events will allow patients to be better informed about the benefit-to-risk ratio of procedures, and guide allotment of limited clinical resources, utilization of preventive interventions, and areas of future research.
  4. The incidence of a major adverse cardiac event of death or myocardial infarction perioperatively is first and foremost related to the baseline risk. The American College of Cardiology/American Heart Association guidelines recommend at least a 60-day interval between an acute coronary syndrome and elective noncardiac surgery.
  5. Current guidelines advise that patients with moderate-to-severe aortic regurgitation and severe aortic regurgitation could be monitored with invasive hemodynamics and echocardiography, in addition to being admitted to an intensive care unit setting in the postoperative period.
  6. Several multivariate risk indexes may be helpful for preoperative assessment. Current guidelines allow use of the National Surgical Quality Improvement Program (NSQIP) Myocardial Infarction and Cardiac Arrest (MICA) calculator, the NSQIP Surgical Risk calculator, or the Revised Cardiac Risk Index (RCRI) as part of a preoperative assessment.
  7. Prophylactic coronary revascularization exclusively to reduce perioperative cardiac events is not recommended, even in patients undergoing elective elevated-risk surgery.
  8. The guidelines continue to provide a Class I recommendation for continuation of beta-blockade therapy for patients on beta-blockers chronically. Patients most likely to benefit from judicious beta-blocker treatment usually already have an indication for such treatment, such as prior systolic heart failure, a myocardial infarction within the past year, or known angina pectoris.
  9. The benefits of anticoagulation perioperatively must be weighed on a case-by-case basis against the risks of bleeding in the particular surgery being planned. In certain circumstances in which there is minimal to no risk of bleeding (such as cataract surgery or minor dermatologic procedures), it may be reasonable to continue anticoagulation perioperatively. For patients with mechanical mitral valves OR a mechanical aortic valve and one additional risk factor (atrial fibrillation, previous venous thromboembolism, left ventricular dysfunction, hypercoagulable state), bridging anticoagulation with unfractionated heparin may be appropriate when the risk of surgical bleeding is more than minimal.
  10. As the US healthcare system finds itself grappling with the goals of better patient care that is cost-effective, further studies on the use of novel perioperative testing and interventions will be needed. Future research focusing on patient outcomes is needed to further clarify the proper care of these patients.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Anticoagulation Management and ACS, Acute Heart Failure, Chronic Heart Failure, Echocardiography/Ultrasound

Keywords: Anticoagulants, Acute Coronary Syndrome, Angina Pectoris, Aortic Valve Insufficiency, Echocardiography, Heart Failure, Systolic, Hemodynamics, Heparin, Myocardial Infarction, Myocardial Ischemia, Perioperative Care, Primary Prevention, Risk, Risk Assessment, Risk Factors, Surgical Procedures, Elective, Surgical Procedures, Operative

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