What is the recommended approach for perioperative risk stratification in primary care?

Perioperative Risk Stratification in Primary Care

The recommended approach for perioperative risk stratification in primary care should include validated risk prediction tools, assessment of functional capacity, and evaluation of surgery-specific risk factors to guide clinical decision-making and optimize patient outcomes. 1

Risk Assessment Framework

Step 1: Evaluate Surgery-Related Risk

• Classify the surgical procedure by risk level (low, intermediate, or high-risk) based on the invasiveness and potential for hemodynamic stress 1
• Emergency procedures carry 2-5 times higher risk than elective surgeries and may limit the ability to perform comprehensive evaluation 1
• Major thoracic, abdominal, and vascular surgeries, especially in patients over 70 years, have higher perioperative cardiac morbidity 1, 2

Step 2: Use Validated Risk Prediction Tools

• The Revised Cardiac Risk Index (RCRI) is a simple, validated tool that assigns 1 point for each of 6 predictors to assess risk of major cardiac complications 1
• American College of Surgeons National Surgical Quality Improvement Program (NSQIP) perioperative MI and cardiac arrest (MICA) risk calculator provides superior predictive discrimination 1
• The universal American College of Surgeons NSQIP surgical risk calculator is a comprehensive 21-component tool 1
• The AUB-HAS2 cardiovascular risk index stratifies patients into low (score 0-1), intermediate (score 2-3), and high risk (score >3) categories based on 6 data elements 1

Step 3: Assess Functional Capacity

• Functional capacity is a critical predictor of perioperative adverse cardiovascular events 1
• Use the Duke Activity Status Index (DASI), a semi-quantitative tool that assesses ability to perform 12 daily activities 1
• Poor functional capacity (inability to achieve 4 METs, equivalent to climbing two flights of stairs) indicates increased risk 1
• In selected cases, exercise stress testing can provide objective assessment of functional capacity 1

Step 4: Evaluate Patient-Specific Risk Factors

• Age-related physiological decline, multi-morbidity, and frailty are independently associated with increased perioperative risk 1
• Key cardiovascular risk factors include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease 1
• Additional risk factors include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency 1
• B-type natriuretic peptide level before surgery is an additional risk stratification factor 1

Step 5: Preoperative Optimization

• Screen for modifiable risk factors including smoking, alcohol usage, undiagnosed hypertension, diabetes, anemia, and nutritional status 1
• Recommend smoking cessation at least 4 weeks before surgery to reduce respiratory and wound-healing complications 1
• Advise alcohol abstinence for 4 weeks prior to surgery 1
• Investigate and correct anemia preoperatively 1
• Consider perioperative statin therapy, which may confer benefits through pleiotropic anti-inflammatory effects 1

Special Considerations

Elderly Patients

• Perform multidisciplinary assessment with early involvement of geriatricians and anesthesiologists 1
• Evaluate minimum criteria for adequate pre-operative geriatric assessment specific to anesthesia 1
• Consider age-related physiological changes that may affect perioperative risk 1

Antithrombotic Management

• Stratify patients for periprocedural thromboembolism risk (high, moderate, or low) based on mechanical heart valves, atrial fibrillation, and venous thromboembolism history 1
• Assess surgery/procedure-related bleeding risk (high, low-to-moderate, or minimal) 1
• Develop an individualized plan for perioperative antithrombotic management based on thrombotic and bleeding risk assessment 1

Cardiovascular Disease

• Patients with coronary artery disease (CAD) have increased risk of perioperative major adverse cardiac events (MACE) 1, 2
• Heart failure, left-sided valvular heart disease, and significant arrhythmic burden also increase perioperative risk 2
• Consider myocardial injury after noncardiac surgery (MINS) surveillance in high-risk patients 1

Common Pitfalls and Caveats

• Risk scores have poorer discrimination in patients undergoing vascular surgery, likely due to underestimation of MI risk 1
• Despite reasonable ability to predict perioperative risk, there have been few studies in which treatment strategies were modified based on preoperative risk prediction tools 1
• Adherence to perioperative management guidelines is often poor, representing a clear opportunity for improving quality of care 1
• Risk prediction tools are limited because they are derived from specific patient populations, are simplified for ease of use, and may not account for improved treatment modalities over time 3
• Avoid relying solely on age as a risk factor; greater risks are associated with urgency and significant cardiac, pulmonary, and renal disease 1

By implementing this structured approach to perioperative risk stratification, primary care physicians can effectively identify high-risk patients, optimize modifiable risk factors, and develop appropriate perioperative management strategies to improve patient outcomes.