What are the requirements for cardiac clearance prior to non-cardiac surgery?

From the Guidelines

Cardiac clearance for non-cardiac surgery should be guided by a thorough preoperative assessment, focusing on optimizing the patient's cardiac status and minimizing perioperative cardiac risk, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Key Considerations

• For patients with coronary stents, elective surgery should be delayed for at least 30 days after bare metal stent (BMS) implantation and ideally 365 days after drug-eluting stent (DES) implantation, unless the risk of delaying surgery outweighs the benefit of reducing perioperative cardiac events 1.
• Beta-blockers should be continued in patients who are on them chronically, and consideration should be given to starting them in patients with intermediate- or high-risk preoperative tests or those with ≥3 Revised Cardiac Risk Index (RCRI) factors, with the goal of initiating them more than 1 day before surgery to assess safety and tolerability 1.
• Statins should be continued in patients currently taking them, and their perioperative initiation is reasonable in patients undergoing vascular surgery or those with clinical risk factors undergoing elevated-risk procedures 1.
• ACE inhibitors or ARBs should be continued perioperatively, and if held before surgery, they should be restarted as soon as clinically feasible postoperatively 1.
• Antiplatelet therapy, including aspirin and P2Y12 inhibitors, should be managed based on the type of stent and the timing of surgery, with the aim of balancing the risk of bleeding against the risk of stent thrombosis 1.

Perioperative Management

• The decision to perform non-cardiac surgery should take into account the patient's overall cardiac risk profile, including the presence of coronary artery disease, heart failure, valvular disease, arrhythmias, or poor functional capacity.
• Preoperative testing such as stress tests or echocardiograms should be ordered selectively based on the patient's risk factors and the type of surgery planned.
• Patients with unstable cardiac conditions should have their surgery postponed until these conditions are stabilized to minimize perioperative cardiac complications.
• A multidisciplinary approach, involving cardiologists, anesthesiologists, and surgeons, is crucial for optimizing perioperative cardiac care and reducing morbidity and mortality in patients undergoing non-cardiac surgery.

From the Research

Cardiac Clearance for Non-Cardiac Surgery

• Cardiac clearance for non-cardiac surgery is crucial to evaluate the risk of perioperative cardiovascular complications, particularly in patients with coronary artery disease (CAD) 2.
• The preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, but excessive evaluation might lead to undue resource utilization and surgical delay 2.
• The optimal approach for perioperative management of patients with CAD undergoing non-cardiac surgery is yet to be determined, and current guidelines do not provide detailed recommendations on this topic 2.

Preoperative Evaluation

• Preoperative evaluation in non-cardiac surgery should include cardiac risk assessment, and high cardiac risk patients can be identified preoperatively in current practice 3.
• Cardiological referral is frequent, and cardiologists may require further tests or modify therapy for high-risk patients 3.
• A stepwise patient evaluation that integrates clinical risk factors, functional status, and the estimated stress of the planned surgical procedure is recommended to reduce perioperative cardiovascular risk 4.

Risk Assessment and Management

• Major guidelines on preoperative cardiovascular risk assessment recommend establishing the risk of surgery per se, evaluating the presence of unstable cardiac conditions, assessing functional capacity, and determining the value of non-invasive and/or invasive cardiovascular testing 4.
• The Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP) scores can be used to estimate perioperative risk for major cardiac adverse events 4.
• The 2022 European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery provide updated recommendations for physicians involved in perioperative care 5.

Medication Management

• Beta-blockers have been used in the symptomatic treatment of ischemic heart disease and in the secondary prevention of myocardial infarction and heart failure, but their continued role in ischemic heart disease has been questioned in the contemporary era 6.
• Few randomized clinical trials are available on the effect of beta-blockers in the reperfusion era, and additional large-scale randomized clinical trials are needed to evaluate the role of beta-blocker therapy in current clinical practice 6.