Reviewing Cardiovascular Risk Assessment, Perioperative Management for Noncardiac Surgery

Comprehensive preoperative assessment of cardiovascular risk is essential prior to noncardiac surgery, according to a study published in JAMA.

The research team searched databases published from 1949 through 2020 for English-language publications related to the evaluation of perioperative cardiovascular risk prior to noncardiac surgery. Publications included in the study were clinical practice guidelines, randomized clinical trials, and meta-analyses of observational studies and trials.

Patient history and a physical examination focused on cardiovascular health should be the first step in evaluating perioperative risk. History should include conditions associated with perioperative major adverse cardiovascular events (MACE), such as ischemic heart disease or heart failure. Risk calculators, such as the Revised Cardiac Risk Index, can identify individuals with low (<1%) or high (>1%) risk for perioperative MACE during the surgical hospital admission or within 30 days of surgery. Patients with a Revised Cardiac Risk Index of 0 have an estimated 0.4% risk for major cardiovascular complications while those with an index of ≥3 have an estimated 10% risk.

The American Heart Association (AHA)/American College of Cardiology (ACC), Canadian Cardiovascular Society, and European Society of Cardiology provide perioperative guideline recommendations for patients for whom perioperative cardiovascular testing is recommended:

• Lead electrocardiography (ECG): Preoperative 12-lead ECG is reasonable in patients with a history of coronary artery disease (CAD), arrhythmias, peripheral artery disease, cerebrovascular disease, or structural heart disease.
• Transthoracic echocardiography: Preoperative echocardiography is reasonable to consider in patients with moderate or severe valvular disease (stenosis or regurgitation) without echocardiography in the past year or those who have new clinical signs or symptoms of severe valvular disease, including dyspnea, angina, edema, or recent syncope.
• Stress testing for myocardial ischemia: Routine stress testing is not indicated for low risk patients (eg, patients with excellent functional capacity). Cardiopulmonary exercise testing may be considered for patients with unknown functional capacity who are scheduled for higher-risk surgical procedures. Among patients with poor functional capacity (<4 metabolic equivalents) at higher risk for noncardiac surgery, exercise testing with cardiac imaging, or noninvasive pharmacologic stress testing to assess for myocardial ischemia is reasonable only if this testing will change perioperative medical management and decisions regarding coronary revascularization.
• Coronary angiography and revascularization: Routine perioperative invasive coronary angiography is not recommended before noncardiac surgery. Invasive angiography may be considered in patients with stress tests that indicate myocardial ischemia, but only if the results of angiography would affect perioperative care. Routine coronary revascularization prior to surgery does not improve perioperative outcomes.
• Biomarker measurement: AHA/ACC guidelines do not formally endorse brain natriuretic peptide measurement as part of preoperative risk assessment since biomarker-based perioperative management strategies have not been tested to reduce cardiovascular risk.

Therapies to reduce perioperative cardiovascular risk include β-blockers, aspirin, lipid-lowering therapy and statins, angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), and oral anticoagulation.

• Patients already taking ß-blockers should continue treatment in the perioperative period, in the absence of bradycardia or hypotension. Initiation of ß-blockers before surgery may be warranted in select patients with CAD or multiple high-risk factors for perioperative myocardial infarction. High-dose ß-blocker therapy should not be initiated on the day of surgery; however, it may be reasonable to initiate ß-blockers >1 week prior to surgery to determine tolerability and safety.
• Routine perioperative low-dose aspirin (100 mg/day) does not decrease cardiovascular events but increases surgical bleeding; however, a subgroup analysis of a randomized trial suggested that aspirin reduces perioperative death or myocardial infarction by 50% in patients with a prior coronary stent.
• Statins are associated with fewer postoperative cardiovascular complications and lower mortality in observational studies and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. Statins may be beneficial in patients with indications for lipid-lowering therapy, such as patients with diabetes or atherosclerotic cardiovascular disease.
• Canadian guidelines recommend withholding ACE inhibitors/ARB for 24 hours prior to noncardiac surgery and resuming this therapy on the second postoperative day. European guidelines recommend considering temporary discontinuation of ACE inhibitors or ARBs prior to surgery when these medications are prescribed for hypertension, but recommend continuing them in stable patients with heart failure and left ventricular systolic dysfunction. AHA/ACC guidelines indicate that it is reasonable to continue ACE inhibitors/ARB and that these agents should be restarted as soon as possible in the postoperative period.
• Perioperative interruption of oral anticoagulation in patients with atrial fibrillation appears safe and perioperative bridging for atrial fibrillation should not be routinely performed. Patients with mechanical mitral valves and those at risk for thrombotic events with mechanical aortic valves should receive bridging anticoagulation with heparin prior to noncardiac surgery.

For older adults, general principles of perioperative risk stratification should be followed, with emphasis on assessing baseline functional impairment. For urgent of emergency surgeries, perioperative cardiovascular evaluation should consider the benefits of surgery and alternatives to surgery in the context of cardiovascular risks. Guideline-recommended cardiovascular evaluation prior to urgent surgery may be appropriate to exclude acute cardiovascular conditions that are contraindications for surgery.

Limitations of the study include the fact that all relevant studies were not considered as a literature search was not performed for each subcategory discussed, as well as the limited quality of evidence related to perioperative care guideline recommendations.

Reference

Smilowitz NR, Berger JS. Cardiovascular risk assessment and management for non-cardiac surgery: a review [published online July 21, 2020]. JAMA.