From the Guidelines
Cardiac surveillance during and after noncardiac surgery should include continuous electrocardiogram monitoring, regular blood pressure measurements, pulse oximetry, and daily assessment of cardiac biomarkers like troponin for high-risk patients, as recommended by the most recent guidelines 1.
Key Components of Cardiac Surveillance
- Preoperative risk stratification using tools like the Revised Cardiac Risk Index to identify patients needing more intensive monitoring
- Maintenance of hemodynamic stability during surgery, avoiding tachycardia and hypotension which can precipitate myocardial ischemia
- Postoperative telemetry monitoring for 24-72 hours, with daily ECGs and cardiac biomarkers for the first 48-72 hours for high-risk patients
- Optimization of medications, including continuation of beta-blockers and statins for patients already on them
- Pain control and careful fluid management to avoid both hypovolemia and fluid overload
- Early mobilization to prevent venous thromboembolism and pulmonary complications
Rationale for Comprehensive Approach
The physiological stress of surgery increases myocardial oxygen demand while potentially decreasing oxygen supply, particularly in patients with underlying coronary artery disease or heart failure 1. Therefore, a comprehensive approach to cardiac surveillance is necessary to minimize the risk of cardiac complications and improve patient outcomes.
Importance of Recent Guidelines
The European Society of Cardiology quality indicators for the cardiovascular pre-operative assessment and management of patients considered for non-cardiac surgery, developed in collaboration with the European Society of Anaesthesiology and Intensive Care, provide a framework for standardizing care and reducing the 'evidence-practice gap' for patients undergoing non-cardiac surgery 1. These guidelines emphasize the importance of a multidisciplinary approach to cardiac surveillance and management, involving surgeons, anesthesiologists, cardiologists, and other healthcare professionals.
From the Research
Cardiac Operative and Postoperative Surveillance in Noncardiac Surgery
- The use of medications such as β blockers, aspirin, and statin in non-cardiac critically ill patients has been studied, with evidence suggesting that these medications may play a role in reducing mortality in these patients 2.
- The decision to use these medications should be based on the severity of illness, with cardiac troponin (cTn) potentially serving as a marker for severity of illness 2.
- β blockers, in particular, have been shown to be effective in reducing mortality in patients with heart failure and atrial fibrillation, with metoprolol succinate being a commonly used agent in these indications 3.
- The choice of β blocker should be based on the individual patient's clinical status and the specific indication being treated, with consideration given to factors such as receptor selectivity, intrinsic sympathomimetic activity, and vasodilating properties 4, 5.
- In patients with chronic obstructive pulmonary disease (COPD), β blockers, aspirin, and statins may be underutilized after myocardial infarction, with increasing severity of COPD being a risk factor for non-use of these medications 6.
Medication Usage in Noncardiac Surgery
- The use of β blockers, aspirin, and statin in non-cardiac surgery should be guided by evidence-based guidelines and individual patient factors, such as severity of illness and cardiac risk factors 2, 6.
- Medication usage should be carefully monitored and adjusted as needed to minimize the risk of adverse events and optimize patient outcomes 4, 5.
- Further research is needed to fully understand the role of these medications in non-cardiac surgery and to develop evidence-based guidelines for their use in this setting 2, 3, 6.