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:

  1. Each year, more than 10 million adults worldwide have major cardiac complications in the first 30 days after noncardiac surgery.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. An elevated preoperative plasma level of B-type natriuretic peptide (BNP) is a particularly strong independent predictor of adverse preoperative outcomes.
  8. In patients with stable coronary artery disease, there are no data to support preoperative coronary revascularization.
  9. Models of shared care between surgeons and internists may improve outcomes for patients.
  10. Most myocardial infarctions occur within 48 hours of noncardiac surgery, when patients are receiving analgesic medications that can mask symptoms of ischemia.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), ACS and Cardiac Biomarkers, Implantable Devices, SCD/Ventricular Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Anesthesia, Angina Pectoris, Coronary Artery Disease, Heart Arrest, Hypothermia, Myocardial Infarction, Natriuretic Peptide, Brain, Quality Improvement, Secondary Prevention, Stents, Stroke, Surgical Procedures, Operative, Sympathetic Nervous System

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