What are the guidelines for cardiac clearance for patients undergoing non-emergent surgery?

Guidelines for Cardiac Clearance for Non-Emergent Surgery

The cardiac clearance process for non-emergent surgery should follow a stepwise approach based on clinical risk factors, functional capacity, and surgical risk to minimize perioperative cardiac complications.

Step 1: Determine Urgency of Surgery

• Assess if surgery is emergent, urgent, or elective 1
• For emergent surgery, proceed with appropriate monitoring and management strategies based on clinical assessment 1

Step 2: Screen for Active Cardiac Conditions

• Identify any active cardiac conditions that require evaluation and treatment before non-cardiac surgery 1:
  • Unstable coronary syndromes (unstable angina, recent MI)
  • Decompensated heart failure
  • Significant arrhythmias
  • Severe valvular disease 1

Step 3: Assess Surgical Risk

• Determine the cardiac risk associated with the planned procedure 1:
  • Low-risk procedures (<1% risk): endoscopy, superficial procedures, cataract surgery, breast surgery
  • Intermediate-risk procedures (1-5% risk): intraperitoneal/intrathoracic procedures, carotid endarterectomy, head and neck surgery
  • High-risk procedures (>5% risk): major vascular procedures, prolonged surgeries with large fluid shifts 1

Step 4: Evaluate Functional Capacity

• Assess the patient's functional capacity in metabolic equivalent tasks (METs) 1:
  • ≥4 METs (can climb ≥2 flights of stairs): proceed with planned surgery without further cardiac testing 1, 2
  • <4 METs or unknown: proceed to Step 5 1

Step 5: Determine Clinical Risk Factors

• Identify clinical risk factors from the Revised Cardiac Risk Index 1:
  • History of ischemic heart disease
  • History of heart failure
  • History of cerebrovascular disease
  • Diabetes mellitus requiring insulin
  • Renal insufficiency (creatinine >2 mg/dL) 1

Step 6: Decision for Further Testing

• For patients with poor functional capacity (<4 METs) 1:
  • With ≥3 clinical risk factors undergoing vascular surgery: consider stress testing 1
  • With 1-2 clinical risk factors undergoing intermediate-risk surgery: proceed with surgery with heart rate control 1
  • With no clinical risk factors: proceed with planned surgery 1

Step 7: Preoperative Testing Recommendations

• Resting 12-lead ECG is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or structural heart disease 1
• Echocardiography is recommended for patients with:
  • Suspected moderate or greater valvular stenosis or regurgitation 1
  • Known or suspected heart failure 1
• Troponin measurement is recommended only for patients with signs or symptoms of myocardial ischemia or MI 1

Special Considerations

Valvular Heart Disease

• For patients with severe valvular heart disease, clinical and echocardiographic evaluation is recommended before non-cardiac surgery 1
• For asymptomatic patients with severe aortic stenosis, elevated-risk elective non-cardiac surgery with appropriate monitoring is reasonable 1
• For symptomatic patients with severe valvular disease, valve intervention before elective non-cardiac surgery is effective in reducing perioperative risk 1

Perioperative Management

• Routine use of pulmonary artery catheterization is not recommended 1
• Prophylactic intravenous nitroglycerin is not effective in reducing myocardial ischemia 1
• Routine use of intraoperative transesophageal echocardiogram is not recommended 1
• Maintenance of normothermia may be reasonable to reduce perioperative cardiac events 1

Common Pitfalls to Avoid

• Routine stress testing in low-risk patients is not recommended and may lead to unnecessary delays in surgery 2
• Routine coronary revascularization before non-cardiac surgery does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 2, 3
• High-dose β-blockers administered shortly before surgery are associated with increased risk of stroke and mortality 2
• Routine postoperative screening with troponin levels in unselected patients without signs or symptoms of myocardial ischemia is not recommended 1