Perioperative cardiovascular risk assessment and management for noncardiac surgery

Approximately 50 million patients undergo noncardiac surgery every year in the US.[1]Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2017 Feb 1;2(2):181-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC5563847 http://www.ncbi.nlm.nih.gov/pubmed/28030663?tool=bestpractice.com ​ Of those, about 750 per 100,000 people have a nonfatal perioperative myocardial infarction (MI). Fatal major cardiovascular and cerebrovascular events occur around 1.67% of cases.[1]Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2017 Feb 1;2(2):181-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC5563847 http://www.ncbi.nlm.nih.gov/pubmed/28030663?tool=bestpractice.com ​ Most perioperative cardiac morbidity and mortality is related to MI, heart failure, cardiogenic shock, or arrhythmias.[1]Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2017 Feb 1;2(2):181-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC5563847 http://www.ncbi.nlm.nih.gov/pubmed/28030663?tool=bestpractice.com ​

Multiple cardiovascular risk factors are present in 45% of surgical inpatients age ≥45 years.[2]Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Nov 5;150(19):e351-442. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001285 http://www.ncbi.nlm.nih.gov/pubmed/39316661?tool=bestpractice.com ​ As the global population ages, the number of patients with significant perioperative cardiac risk undergoing noncardiac surgery can be expected to increase.

Preoperative cardiac risk assessment and perioperative management emphasize the detection, characterization, and management of cardiac disorders in appropriate patients. Patients with known or suspected coronary artery disease (CAD), arrhythmias, history of heart failure, or current symptoms consistent with these conditions should also undergo assessment. In people age ≥45 years, a more extensive history and physical exam is warranted.

The purpose of individual preoperative cardiac risk assessment is to:[2]Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Nov 5;150(19):e351-442. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001285 http://www.ncbi.nlm.nih.gov/pubmed/39316661?tool=bestpractice.com [3]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 ​​​[4]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 [5]Sazgary L, Puelacher C, Lurati Buse G, et al. Incidence of major adverse cardiac events following non-cardiac surgery. Eur Heart J Acute Cardiovasc Care. 2021 Jun 30;10(5):550-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC8245139 http://www.ncbi.nlm.nih.gov/pubmed/33620378?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 (e.g., cardiovascular death, acute heart failure, MI, or hemodynamically relevant arrhythmia)

• 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.

Patients are at highest risk of perioperative cardiac events in the first 30 days following surgery, but risk remains elevated for about 5 months.[5]Sazgary L, Puelacher C, Lurati Buse G, et al. Incidence of major adverse cardiac events following non-cardiac surgery. Eur Heart J Acute Cardiovasc Care. 2021 Jun 30;10(5):550-8. https://pmc.ncbi.nlm.nih.gov/articles/PMC8245139 http://www.ncbi.nlm.nih.gov/pubmed/33620378?tool=bestpractice.com