From the Guidelines
Cardiac evaluation before anesthesia in noncardiac surgery should follow a risk-stratified approach based on patient factors, surgical complexity, and functional capacity. This approach is supported by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The guideline emphasizes the importance of a thorough history and physical examination, focusing on cardiac symptoms, exercise tolerance, and risk factors.
Key Considerations
- For low-risk procedures in healthy patients, no further testing is typically needed.
- For intermediate-risk surgeries or patients with stable cardiac disease, proceed with surgery if functional capacity exceeds 4 METs.
- Additional testing is warranted for high-risk surgeries, poor functional capacity (<4 METs), or unstable cardiac conditions.
- Specific tests include electrocardiogram for patients over 65 or with cardiovascular disease, echocardiography for suspected valvular disease or heart failure, and stress testing for patients with multiple risk factors.
Medication Management
- Medications should generally be continued perioperatively, especially beta-blockers, statins, and antihypertensives, though ACE inhibitors may be held on the day of surgery 1.
- Antiplatelet therapy management depends on thrombotic versus bleeding risk.
Goal of Evaluation
The goal of preoperative evaluation is to promote patient engagement and facilitate shared decision making by providing patients and their providers with clear, understandable information about perioperative cardiovascular risk in the context of the overall risk of surgery 1. This approach balances the need to identify significant cardiac conditions against avoiding unnecessary testing that may delay surgery without improving outcomes. The goal is to optimize cardiac status before surgery while recognizing that extensive preoperative testing has not been shown to significantly reduce perioperative cardiac events in most patients 1.
From the Research
Cardiac Evaluation on Anesthesia in Noncardiac Surgery
- Cardiac evaluation is crucial before noncardiac surgery to assess the risk of perioperative cardiovascular complications, which occur in 3% of hospitalizations for noncardiac surgery in the US 2.
- A focused history and physical examination are required 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.
Preoperative Cardiovascular Risk Assessment
- Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk 2, 3.
- Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery 2, 4.
- Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery 4.
Management of Patients Undergoing Noncardiac Surgery
- Statins are associated with fewer postoperative cardiovascular complications and lower mortality, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 2.
- High-dose β-blockers should not be routinely used, as they are associated with a higher risk of stroke and mortality 2.
- Close liaison between general practitioners, surgeons, anaesthetists, and cardiologists is needed for optimizing preoperative management and subsequent clinical outcomes in high-risk patients 5.