What is the recommended pre-procedure management for patients with low or medium intrinsic cardiac risk?

Pre-Procedure Management for Low or Medium Intrinsic Cardiac Risk

For patients with low or medium intrinsic cardiac risk undergoing non-cardiac surgery, proceed directly to surgery without additional cardiac testing if the patient is asymptomatic or cardiac-stable with functional capacity >4 METs (can climb 2 flights of stairs without symptoms). 1

Risk Stratification Framework

Surgical Risk Classification

• Low-risk procedures (<1% cardiac risk): Proceed to surgery with identification of risk factors and recommendations for lifestyle and medical therapy 1
• Intermediate-risk procedures (1-5% cardiac risk): Assess patient functional capacity before determining need for testing 1

Patient Functional Capacity Assessment

• If functional capacity ≥4 METs: Proceed directly to surgery regardless of clinical risk factors present 1
• If functional capacity <4 METs or unknown: Consider non-invasive stress testing only if results would change perioperative management 1

Pre-Procedure Medical Optimization

Medications to Continue

• Beta-blockers: Continue in patients already taking them chronically (do not initiate de novo) 1
• Statins: Continue and consider initiating in patients with atherosclerotic cardiovascular disease, particularly for vascular surgery 1
• Aspirin: Continue in patients with established indications 1

Medications to Optimize

• ACE inhibitors/ARBs: Consider in patients with heart failure and systolic LV dysfunction (LVEF <40%) 2
• Diabetes medications: Optimize glycemic control before elective surgery 2
• Antihypertensives: Ensure blood pressure is controlled 2

Lifestyle Modifications

Preoperative Interventions

• Smoking cessation: Implement at least 4 weeks before surgery to reduce respiratory and wound-healing complications 2
• Alcohol abstinence: Strongly recommended for 4 weeks preoperatively in patients consuming >2 units daily 2

When Additional Testing is NOT Indicated

Do not perform routine preoperative cardiac testing in the following scenarios:

• Low-risk surgery (<1% cardiac risk) regardless of patient factors 1, 3
• Intermediate-risk surgery with good functional capacity (≥4 METs) even with clinical risk factors present 1
• Asymptomatic patients with preserved functional capacity 1

When Additional Testing MAY Be Considered

Non-invasive stress testing may be reasonable only if ALL of the following criteria are met:

• Intermediate or high-risk surgery (≥1% cardiac risk) 1
• Poor functional capacity (<4 METs) or unknown functional capacity 1
• Multiple clinical risk factors present (≥2 on Revised Cardiac Risk Index) 1
• Test results would change perioperative medical, anesthesia, or surgical management 1

Interpretation of Stress Testing

• No ischemia or mild-to-moderate ischemia (1-2 vessel disease): Proceed with surgery; initiate statin and titrated low-dose beta-blocker 1
• Extensive stress-induced ischemia: Individualized management considering surgical benefit versus predicted adverse outcome; assess need for medical therapy optimization or coronary revascularization 1

Common Pitfalls to Avoid

Critical Errors in Management

• Do not delay surgery for cardiac testing unless acute cardiac symptoms are present or patient would require coronary revascularization independent of planned surgery 2, 4
• Do not perform routine coronary revascularization before non-cardiac surgery as it does not reduce perioperative risk in stable coronary disease 1
• Do not initiate high-dose beta-blockers 2-4 hours before surgery as this increases stroke (1.0% vs 0.5%) and mortality (3.1% vs 2.3%) 5
• Do not routinely start low-dose aspirin perioperatively as it does not decrease cardiovascular events but increases surgical bleeding 5

Testing Pitfalls

• Do not perform tests that will not influence perioperative management 2, 3, 4
• Do not order routine ECGs, laboratory tests, chest X-rays, or cardiac stress testing for asymptomatic patients undergoing low-risk procedures 3

Perioperative Monitoring Considerations

Intraoperative Management

• Control heart rate, particularly in patients with mitral stenosis 1
• Avoid fluid overload and volume depletion 1
• Prevent hypotension, particularly in patients with aortic stenosis 1
• Optimize anticoagulation if needed 1

Postoperative Care

• Monitor for cardiac complications including myocardial ischemia, heart failure, and arrhythmias 2
• Restart ACE inhibitors only after confirming euvolemic status to decrease perioperative renal dysfunction risk 2

Multidisciplinary Communication

Essential coordination required between:

• Cardiologists, anesthesiologists (ideally cardiac anesthesiologists), surgeons, and the patient/family 1, 2
• Treatment options for patients with active cardiac conditions should be discussed in multidisciplinary team 1