In an adult with New York Heart Association (NYHA) class II heart failure, left bundle‑branch block (LBBB), septal dyssynchrony, global left‑ventricular hypokinesia and a reduced ejection fraction (~35 %), should coronary angiography be performed and antiplatelet therapy be initiated before non‑cardiac surgery, and how should he be risk‑stratified?

Preoperative Cardiac Risk Stratification and Management for Non-Cardiac Surgery

In this patient with NYHA class II heart failure, LBBB, LVEF 35%, and global hypokinesia, antiplatelet therapy should NOT be routinely started before surgery unless there is a specific indication such as recent coronary intervention or acute coronary syndrome, and coronary angiography is NOT routinely indicated before non-cardiac surgery unless the patient has active cardiac conditions or would require revascularization independent of the planned surgery.

Risk Stratification Approach

This patient requires careful preoperative risk assessment based on their significant cardiac comorbidities:

Clinical Risk Assessment

• NYHA class II with LVEF 35% places this patient at elevated perioperative risk 1
• The presence of LBBB with global hypokinesia suggests underlying cardiomyopathy that may be ischemic or non-ischemic in origin 2, 3
• LBBB itself is associated with worse outcomes, including higher mortality (HR 1.17) and progression to more severe LV dysfunction (HR 1.34) even in patients with mildly to moderately reduced LVEF 3

Coronary Angiography Decision

Coronary angiography is NOT routinely indicated for preoperative evaluation unless:

• The patient has active cardiac conditions (unstable angina, recent MI, decompensated heart failure, significant arrhythmias, severe valvular disease)
• The patient would require coronary revascularization independent of the planned surgery based on symptoms or high-risk features
• There is clinical suspicion of acute coronary syndrome

The presence of LBBB, reduced LVEF, and global hypokinesia alone do not mandate preoperative angiography 1.

Antiplatelet Therapy Decision

Antiplatelet therapy should NOT be initiated solely for preoperative risk reduction unless there is a specific indication:

• Recent coronary stenting (within 12 months for drug-eluting stents, 1 month for bare-metal stents)
• Documented coronary artery disease with prior MI or revascularization
• Acute coronary syndrome

Starting antiplatelet therapy before non-cardiac surgery without these indications increases bleeding risk without proven benefit 1.

Critical Management Priorities Before Surgery

Optimize Heart Failure Medical Therapy

The patient should be on guideline-directed medical therapy (GDMT) for at least 3 months before considering device therapy 1, 4:

• Beta-blockers (carvedilol 25-50 mg twice daily, metoprolol succinate 200 mg daily, or bisoprolol 10 mg daily) 5
• ACE inhibitors, ARBs, or ARNI
• Mineralocorticoid receptor antagonists if appropriate 1
• SGLT2 inhibitors 1

Consider Cardiac Resynchronization Therapy (CRT)

This patient meets criteria for CRT evaluation given:

• NYHA class II symptoms
• LVEF ≤35%
• LBBB pattern (QRS morphology critical to determine)
• Sinus rhythm (assumed from ECG description)

CRT Indications Based on QRS Duration:

If QRS ≥150 ms with LBBB morphology:

• Class I recommendation for CRT (with or without ICD) 1
• This provides the strongest evidence for benefit in mortality and hospitalization reduction 1

If QRS 120-149 ms with LBBB morphology:

• Class I recommendation for CRT, though benefit is somewhat less robust than with QRS ≥150 ms 1

If non-LBBB pattern:

• Evidence is weaker, particularly if QRS <150 ms 1
• Class IIb recommendation if QRS 120-149 ms with non-LBBB pattern 1

Timing Considerations

CRT should ideally be implanted BEFORE non-cardiac surgery if the patient meets criteria, as:

• LBBB-induced cardiomyopathy may be reversible with CRT 4, 6
• Patients with preserved lateral wall function have better CRT response (54% achieve LVEF normalization vs 13% with lateral wall dysfunction) 6
• The presence of septal flutter and global hypokinesia suggests mechanical dyssynchrony that may respond to CRT 6
• Delaying CRT allows progressive LV dysfunction and adverse remodeling 2, 3

However, patients should not be implanted during acute decompensation and should be stabilized on GDMT first 1.

Perioperative Management Strategy

If Surgery Cannot Be Delayed:

1. Optimize volume status and ensure euvolemia
2. Continue beta-blockers perioperatively (target heart rate <70 bpm at rest) 5
3. Continue other GDMT medications unless contraindicated
4. Close hemodynamic monitoring during and after surgery
5. Plan for postoperative CRT evaluation if criteria met

Common Pitfalls to Avoid:

• Do not stop beta-blockers perioperatively unless absolutely necessary 5
• Do not start antiplatelet therapy without specific indication (increases bleeding risk)
• Do not delay appropriate CRT indefinitely waiting for medical optimization alone 4
• Do not assume LBBB is benign - it portends worse outcomes even with mildly reduced LVEF 3

Risk Stratification Summary

This patient is at elevated perioperative risk due to:

• Reduced LVEF (35%)
• NYHA class II symptoms
• LBBB with mechanical dyssynchrony
• Global hypokinesia

The surgical risk should be assessed based on the type and urgency of the planned non-cardiac surgery, with consideration for:

• Delaying elective surgery to optimize medical therapy and consider CRT if indicated
• Proceeding with urgent/emergent surgery with optimized medical management and close monitoring
• Postoperative CRT evaluation as a priority if not done preoperatively 1