Preoperative cardiac risk assessment

Approximately 27 million patients undergo noncardiac surgery every year in the US.[1]Gregoratos G. Current guideline-based preoperative evaluation provides the best management of patients undergoing noncardiac surgery. Circulation. 2008;117:3134-3144. http://circ.ahajournals.org/content/117/24/3134.full.pdf+html http://www.ncbi.nlm.nih.gov/pubmed/18559713?tool=bestpractice.com Of those, about 50,000 have a perioperative myocardial infarction (MI). Furthermore, over one half of the 40,000 perioperative deaths each year are caused by cardiac events.[2]National Center for Health Statistics. Vital statistics of the United States: 1988, 3. DHHS pub no (PHS) 89-1232. Washington, DC: NCHS US Public Health Services; 1989:10-17,66,67,100,101. Most perioperative cardiac morbidity and mortality is related to MI, heart failure, or arrhythmias. Patients over 65 years of age are at higher risk of cardiac disease, cardiac morbidity, and death. Considering that this patient population will greatly increase over the coming decades, the number of patients with significant perioperative cardiac risk undergoing noncardiac surgery can be expected to increase globally. Patients with congenital heart disease, especially those with unrepaired lesions or a residual lesion burden and compromised cardiovascular status, also require individualized perioperative management.

Preoperative cardiac risk assessment and perioperative management emphasize the detection, characterization, and treatment of coronary artery disease (CAD), left ventricular (LV) systolic dysfunction, and significant arrhythmias in appropriate patients. The American Heart Association/American College of Cardiology (AHA/ACC) guidelines for managing adults with congenital heart disease recommend a stepwise approach to preoperative cardiac assessment, but there are currently no guidelines for comprehensive perioperative care of children with congenital heart disease undergoing noncardiac surgery.[3]Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Apr 2;139(14):e698-800. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000603 http://www.ncbi.nlm.nih.gov/pubmed/30586767?tool=bestpractice.com [4]Nasr VG, Markham LW, Clay M, et al. Perioperative considerations for pediatric patients with congenital heart disease presenting for noncardiac procedures: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2023 Jan;16(1):e000113. https://www.ahajournals.org/doi/full/10.1161/HCQ.0000000000000113 http://www.ncbi.nlm.nih.gov/pubmed/36519439?tool=bestpractice.com ​​ Patients with known or suspected CAD, arrhythmias, history of heart failure, or current symptoms consistent with these conditions should also undergo assessment. In people ages ≥50 years, a more extensive history and physical exam is warranted.

The purpose of individual preoperative cardiac risk assessment is to:[5]Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022 Oct 14;43(39):3826-924. https://www.doi.org/10.1093/eurheartj/ehac270 http://www.ncbi.nlm.nih.gov/pubmed/36017553?tool=bestpractice.com ​​[6]Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64:e77-e137. http://circ.ahajournals.org/content/130/24/e278.full.pdf+html http://www.ncbi.nlm.nih.gov/pubmed/25091544?tool=bestpractice.com [7]Anderson JL, Antman EM, Harold JG, et al. Clinical practice guidelines on perioperative cardiovascular evaluation: collaborative efforts among the collaborative efforts among the ACC, AHA, and ESC. Circulation. 2014;130:2213-2214. http://circ.ahajournals.org/content/130/24/2213 http://www.ncbi.nlm.nih.gov/pubmed/25085963?tool=bestpractice.com

• Assess the medical status of the patient and the cardiac risks posed by the planned noncardiac surgery

• Recommend appropriate strategies to reduce the risk of cardiac problems over the entire perioperative period, and to improve long-term cardiac outcomes.

The main overall goals of assessment are to:

• Identify patients at increased risk of an adverse perioperative cardiac event

• Identify patients with a poor long-term prognosis due to cardiovascular disease. Even though the risk at the time of noncardiac surgery may not be prohibitive, appropriate treatment will affect long-term prognosis.

The nature of the evaluation should be individualized to the patient and the specific clinical scenario:

• Patients presenting with an acute surgical emergency require only a rapid preoperative assessment, with subsequent management directed at preventing or minimizing cardiac morbidity and death. Such patients can often be more thoroughly evaluated after surgery.

• Patients undergoing an elective procedure with no surgical urgency can undergo a more thorough preoperative evaluation.