How can cardiovascular risk be managed in patients undergoing orthopedic surgery?

From the Guidelines

Cardiovascular risk in orthopedic surgery patients should be managed through a comprehensive approach that begins with preoperative risk assessment using validated tools like the Revised Cardiac Risk Index, as recommended by the 2014 ESC/ESA guidelines 1.

Key Considerations

• Patients with established cardiovascular disease should continue their cardiac medications, particularly beta-blockers, statins, and antiplatelet agents, through the perioperative period with minimal interruption.
• For antiplatelet therapy, aspirin can often be continued safely, while P2Y12 inhibitors like clopidogrel should be discontinued 5-7 days before surgery if possible.
• Perioperative beta-blockade should be maintained in patients already taking these medications but not newly initiated immediately before surgery, as stated in the 2009 ACCF/AHA focused update on perioperative beta blockade 1.
• Statins should be continued or started preoperatively as they reduce perioperative cardiac events.

Preoperative Management

• Blood pressure should be optimized to <140/90 mmHg before elective procedures.
• Initiation of a beta-blocker regimen may be considered prior to surgery in patients with known IHD or myocardial ischaemia, with treatment ideally started between 30 days and a minimum of 2 days before surgery, as recommended by the 2014 ESC/ESA guidelines 1.

Intraoperative and Postoperative Care

• Intraoperatively, maintaining hemodynamic stability, avoiding hypotension, and ensuring adequate oxygenation are crucial.
• Postoperatively, early mobilization, appropriate pain management, and vigilant monitoring for cardiac complications like myocardial injury after noncardiac surgery (MINS) are essential.
• Thromboprophylaxis with low molecular weight heparin (e.g., enoxaparin 40mg daily) or direct oral anticoagulants should be provided according to procedure-specific risk.

Procedure-Specific Risk

• The surgery-specific cardiac risk of noncardiac surgery is related to two important factors: the type of surgery itself and the degree of hemodynamic cardiac stress, as discussed in the 2007 ACC/AHA guidelines 1.
• Depending on the noncardiac surgical procedure, it may be associated with profound alterations in heart rate, blood pressure, vascular volume, pain, bleeding, clotting tendencies, oxygenation, neurohumoral activation, and other perturbations.

From the Research

Cardiovascular Risk Management in Orthopedic Surgery

• Cardiovascular risk management is crucial in patients undergoing orthopedic surgery, as perioperative thrombotic complications can lead to significant morbidity and mortality 2.
• The use of aspirin to reduce perioperative cardiovascular complications in high-risk patients remains controversial, but studies suggest that it may be safe and effective in certain cohorts 2.
• The American College of Cardiology/American Heart Association (ACC/AHA) preoperative cardiac assessment guidelines can help identify patients at high risk of major cardiac events and guide management decisions 3.

Preoperative Optimization

• Preoperative optimization of patients with heart failure undergoing cardiac surgery is critical to reduce perioperative complications and mortality 4.
• This includes optimizing end-organ dysfunction, medication, and nutritional status, as well as measuring levels of natriuretic peptides to provide additional prognostic value 4.
• Similar principles can be applied to patients undergoing orthopedic surgery, particularly those with comorbidities such as coronary artery disease, heart failure, and significant arrhythmic burden 5, 6.

Risk Stratification and Management

• Risk stratification is essential to identify patients at high risk of perioperative major adverse cardiovascular events (MACE) and to optimize risk factors prior to surgical intervention 5, 6.
• Noninvasive and invasive cardiac testing can be used to further assess cardiac risk, and perioperative pharmacotherapies such as beta-blockers can be employed to reduce risk 3, 5.
• A multidisciplinary approach to preoperative evaluation and perioperative management can help reduce the risks of major postoperative complications and improve patient outcomes 6.