From the Guidelines
Preoperative cardiac evaluation is crucial for patients undergoing noncardiac surgery with anesthesia to minimize cardiovascular complications, and it should be tailored to the patient's risk factors, surgical complexity, and functional capacity. The evaluation process should consider the patient's medical history, physical examination, and laboratory tests to identify potential cardiac risks.
Key Considerations
- For low-risk procedures (such as cataract surgery or superficial procedures) in patients without significant cardiac disease, minimal evaluation is needed 1.
- For intermediate to high-risk surgeries or patients with known cardiac conditions, a more thorough assessment including ECG, echocardiography, and possibly stress testing may be necessary 1.
- Beta-blockers (such as metoprolol 25-100 mg twice daily) should be continued perioperatively in patients already taking them but not initiated immediately before surgery 1.
- Statins should be continued through the perioperative period 1.
- Antiplatelet therapy management depends on the indication and surgical bleeding risk—aspirin may be continued for secondary prevention in high-risk patients, while P2Y12 inhibitors typically require discontinuation 5-7 days before surgery 1.
High-Risk Patients
Patients with severe valvular disease, recent myocardial infarction (within 6 months), decompensated heart failure, significant arrhythmias, or severe pulmonary hypertension warrant cardiology consultation before proceeding with elective procedures 1.
Communication and Teamwork
The anesthesiologist should be informed of all cardiac conditions and medications to guide appropriate anesthetic technique selection and intraoperative monitoring 1. This systematic approach helps balance the risks of perioperative cardiac events against the benefits of the planned surgical procedure.
Recent Guidelines
The 2014 ESC/ESA guidelines on non-cardiac surgery provide a comprehensive framework for cardiovascular assessment and management, emphasizing the importance of teamwork and communication between cardiologists, surgeons, pulmonologists, and anesthesiologists 1.
From the FDA Drug Label
Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery; however, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures
The use of beta-blockers like metoprolol in patients undergoing noncardiac surgery requires careful consideration. Beta-blocker therapy should not be withdrawn prior to major surgery, as this may increase the risk of severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias. However, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures.
- Key considerations include:
- The patient's cardiac status and risk factors for cardiac complications
- The type and duration of surgery
- The potential benefits and risks of continuing or discontinuing beta-blocker therapy
- The need for careful monitoring and management of the patient's cardiac status during surgery 2
From the Research
Cardiac Evaluation on Anesthesia Use in Noncardiac Surgery
- The American College of Cardiology and American Heart Association clinical practice guideline for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery provides a stepwise approach for the identification and management of patients at highest risk for major adverse cardiac events 3.
- Preoperative evaluation and medical optimisation can improve outcomes, although the evidence base is limited, with strongest evidence for prophylactic use of β-blockers in high-risk patients and aspirin in patients with coronary artery disease 4.
- Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease, with risk calculators such as the Revised Cardiac Risk Index identifying individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events 5.
Recommendations for Cardiac Evaluation
- β-blockers should be continued perioperatively but treatment should not be initiated within 24 h of noncardiac surgery 3.
- Angiotensin-converting enzyme inhibitors should be continued, but if held, may be restarted as soon as feasible 3.
- Routine aspirin therapy is not recommended without previous coronary stent implantation or risk assessment for myocardial ischemia 3.
- Elective noncardiac surgery should not be performed within 30 days of bare metal stent or 12 months of drug-eluting stent implantation 3.
Risk Assessment and Management
- Cardiovascular testing is rarely indicated in patients at low risk for 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 5.
- Statins are associated with fewer postoperative cardiovascular complications and lower mortality in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery 5.
- High-dose β-blockers administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke and mortality, and should not be routinely used 5.
- Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk 5.