What are the strategies for perioperative surveillance in non-cardiac surgery?

From the Guidelines

Perioperative surveillance for noncardiac surgery should include preoperative risk assessment, intraoperative monitoring, and postoperative surveillance tailored to the patient's risk factors, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The goal of perioperative surveillance is to identify patients at high risk for cardiac complications and to implement strategies to reduce this risk.

• Preoperative evaluation should include cardiac risk assessment using tools like the Revised Cardiac Risk Index, which identifies high-risk patients who may benefit from additional monitoring.
• Laboratory testing should include complete blood count, basic metabolic panel, coagulation studies, and cardiac biomarkers for high-risk patients.
• Intraoperative monitoring should include continuous ECG, blood pressure monitoring, pulse oximetry, and capnography, with arterial lines and central venous pressure monitoring for higher-risk cases.
• Postoperatively, cardiac monitoring should be continued for 24-72 hours in high-risk patients, with serial troponin measurements at baseline, 6-12 hours after surgery, and then daily for 2-3 days to detect myocardial injury. The importance of teamwork and communication between surgeon, anesthesiologist, primary caregiver, and consultant is emphasized in the 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1. Early mobilization, adequate pain control with multimodal analgesia, and respiratory care including incentive spirometry are essential to prevent complications. Maintaining appropriate hemodynamic parameters, with target systolic blood pressure within 10-20% of baseline, heart rate 60-100 beats per minute, and oxygen saturation above 94%, is crucial to reducing morbidity and mortality in the perioperative period. The 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery provides further guidance on the use of beta blockers in patients undergoing noncardiac surgery 1. Additionally, the 2007 ACC/AHA guidelines highlight areas in need of further research, including the benefit of cardiac testing and preoperative cardiac evaluation, the cost-effectiveness of various methods of cardiac testing, and the efficacy of monitoring patients for myocardial ischemia and infarction 1.

From the Research

Perioperative Noncardiac Surgery Surveillance Strategies

• Preoperative cardiovascular risk assessment is crucial for patients undergoing noncardiac surgery, with a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease 2
• Risk calculators, such as the Revised Cardiac Risk Index, can identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events 2
• Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events, but may be considered in patients at higher risk if the results would change the perioperative medical, anesthesia, or surgical approaches 2, 3

Patient-Specific Risk Factors

• Adults aged 75 years or older and patients with coronary stents are at higher risk of perioperative myocardial infarction and major adverse cardiovascular events 2
• Patients with atherosclerotic cardiovascular disease undergoing vascular surgery may benefit from preoperative statin use, which is associated with fewer postoperative cardiovascular complications and lower mortality 2
• High-dose β-blockers should not be routinely used, as they are associated with a higher risk of stroke and mortality 2

Perioperative Medical Therapy

• Perioperative medical therapy should be prescribed based on patient-specific risk, with consideration of the patient's medical history, functional capacity, and surgical risk 2, 3
• Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 2
• Routine perioperative use of low-dose aspirin does not decrease cardiovascular events but does increase surgical bleeding 2