What are the requirements for cardiac clearance prior to surgery?

From the Guidelines

Cardiac clearance for surgery should be guided by the estimated 30-day cardiac risk of the procedure, with low-risk procedures (<1%) not requiring extensive preoperative cardiac evaluation, as stated in the 2014 ESC/ESA guidelines 1. The evaluation of cardiac risk for non-cardiac surgery involves determining the risk of the surgical procedure and the patient's cardiac stability.

• In cardiac-stable patients, the risk of the surgical procedure should be determined, and if the estimated 30-day cardiac risk is low (<1%), it is unlikely that test results will influence management, and the planned surgical procedure can proceed 1.
• The physician should identify risk factors and provide recommendations on lifestyle and medical therapy to improve long-term outcomes, as outlined in the guidelines 1.
• Initiation of a beta-blocker regimen may be considered prior to surgery in patients with known ischemic heart disease (IHD) or myocardial ischemia, with treatment ideally started between 30 days and a minimum of 2 days before surgery and continued post-operatively 1.
• Beta-blockade should be started with a low dose, slowly up-titrated, and tailored to achieve a resting heart rate of between 60 and 70 bpm with systolic blood pressure >100 mm Hg 1.
• In patients with heart failure and systolic left ventricular (LV) dysfunction, indicated by left ventricular ejection fraction (LVEF) <40%, angiotensin-converting enzyme inhibitors (ACEIs) (or angiotensin receptor blockers (ARBs) in patients intolerant of ACEIs) should be considered before surgery 1.
• In patients undergoing vascular surgery, initiation of statin therapy should be considered 1.
• Discontinuation of aspirin should be considered in those patients in whom hemostasis is difficult to control during surgery 1. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines also provide recommendations for perioperative cardiovascular evaluation and management of patients undergoing non-cardiac surgery 1.
• The guidelines recommend continuing beta-blockers in patients who are on beta-blockers chronically and guiding management of beta-blockers after surgery by clinical circumstances 1.
• Perioperative statin therapy is recommended for patients undergoing vascular surgery, and initiation of statin use may be considered in patients with a clinical risk factor who are undergoing elevated-risk procedures 1.
• The guidelines also provide recommendations for the management of antiplatelet agents, including continuing dual antiplatelet therapy (DAPT) in patients undergoing urgent non-cardiac surgery during the first 4 to 6 weeks after bare metal stent (BMS) or drug-eluting stent (DES) implantation, unless the risk of bleeding outweighs the benefit of stent thrombosis prevention 1.

From the Research

Cardiac Clearance for Surgery

• Cardiac clearance for surgery involves assessing a patient's risk of perioperative cardiovascular complications, such as myocardial infarction or heart failure 2, 3.
• A stepwise approach to evaluating cardiovascular risk includes assessing clinical risk factors, functional status, and the estimated stress of the planned surgical procedure 3.
• The Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP) can be used to estimate perioperative risk for major cardiac adverse events 2, 3.

Preoperative Assessment

• A comprehensive history, physical examination, and assessment of functional capacity should be performed prior to noncardiac surgery to assess cardiovascular risk 2.
• Cardiovascular testing, such as stress testing, may be considered in patients at higher risk of perioperative cardiovascular complications if the results would change the perioperative medical, anesthesia, or surgical approaches 2.
• Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 2.

Medical Management

• Statins are associated with fewer postoperative cardiovascular complications and lower mortality in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 2.
• The combined use of aspirin, a statin, and blood pressure-lowering agents may reduce the risk of vascular morbidity and mortality in patients with coronary artery disease 4.
• Statin therapy may reduce the rate of heart failure hospitalization and atherosclerotic events in patients with established heart failure, although the evidence is weak and the benefit may be small 5.

Special Considerations

• Patients aged 75 years or older and those with coronary stents are at higher risk of perioperative myocardial infarction and major adverse cardiovascular events and warrant careful preoperative consideration 2.
• The COVID-19 pandemic has highlighted the need for specific strategies to minimize the risk of transmission during the preoperative risk assessment process 3.