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. These include patients with known or suspected CAD, arrhythmias, history of heart failure, or current symptoms consistent with these conditions. In people aged 50 years or older, a more extensive history and physical exam is warranted.
Approximately 27 million patients undergo noncardiac surgery every year in the US. 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. 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.
The purpose of individual preoperative cardiac risk assessment is to:
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.
- Stepwise management approach
- History and physical examination
- Functional capacity assessment
- Cardiac risk stratification using clinical predictors and risk models
- Risk stratification according to type of noncardiac surgery
- Diagnostic tests
- Cardiac risk stratification using stress testing
- ACS NSQIP universal surgical risk calculator
- Perioperative therapy
- Preoperative revascularization with coronary artery bypass grafting or percutaneous coronary intervention
- Special circumstances
- American College of Cardiology/American Heart Association (ACC/AHA) guidelines synopsis
- European Society of Cardiology (ESC) guideline synopsis
- Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment synopsis
Debabrata Mukherjee, MD, FACC
Department of Internal Medicine
Professor of Internal Medicine
Texas Tech University Health Sciences Center
DM declares that he has no competing interests.
Martin Bocks, MD
University of Michigan Congenital Heart Center
MB declares that he has no competing interests.
Andrew Turley, MB ChB
Cardiology Specialist Registrar
The James Cook University Hospital
AT declares that he has no competing interests.
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