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Perioperative cardiac risk management for noncardiac surgery

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of perioperative cardiac risk management for noncardiac surgery are prepared by our editorial team based on guidelines from the Society of Cardiovascular Computed Tomography (SCCT/SVM/SCMR/SCA/AHA/ASNC/HRS/ACC/ACS 2024), the European Society for Vascular Surgery (ESVS 2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the European Society of Cardiology (ESC 2023,2022,2021), ...
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Classification and risk stratification

Cardiac risk assessment
As per ACC/ACS/AHA/…/SVM 2024 guidelines:
Use a validated risk-prediction tool to estimate the risk of perioperative major adverse cardiovascular events in patients with known CVD undergoing NCS.
B
Consider obtaining a structured assessment of functional capacity, such as the Duke Activity Status Index, to stratify the risk of perioperative adverse cardiovascular events in patients undergoing elevated-risk NCS.
C
Duke Activity Status Index (DASI)
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When to use
Is the patient able to take care of self (such as eating, dressing, bathing, using the toilet)?
Yes
No
Is the patient able to walk indoors?
Yes
No
Is the patient able to walk 1-2 blocks on level ground?
Yes
No
Is the patient able to climb a flight of stairs or walk up a hill?
Yes
No
Is the patient able to run a short distance?
Yes
No
Is the patient able to do light work around the house (such as dusting, washing dishes)?
Yes
No
Is the patient able to do moderate work around the house (such as vacuuming, sweeping, carrying groceries)?
Yes
No
Is the patient able to do heavy work around the house (such as scrubbing floors, moving furniture)?
Yes
No
Is the patient able to do yardwork (such as raking leaves, weeding, mowing)?
Yes
No
Is the patient able to have sexual relations?
Yes
No
Is the patient able to participate in moderate recreational activities (such as golf, bowling, dancing)?
Yes
No
Is the patient able to participate in strenuous sports (such as swimming, singles tennis)?
Yes
No
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  • Frailty assessment

Diagnostic investigations

History and physical examination: as per ESC 2022 guidelines, elicit an accurate history and obtain a clinical assessment in all patients scheduled for NCS.
B
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  • ECG (low-risk patients)

  • ECG (high-risk patients)

  • Cardiac biomarkers

  • Echocardiography

  • Stress testing

  • Coronary CTA

  • Hemoglobin levels

  • Screening for sleep obstructive apnea

Diagnostic procedures

Coronary angiography: as per ACC/ACS/AHA/…/SVM 2024 guidelines, do not obtain routine preoperative invasive coronary angiography in patients undergoing NCS.
D
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Medical management

General principles: as per ESC 2022 guidelines, optimize guideline-recommended treatment of CVD and cardiovascular risk factors before NCS if time allows.
B
control cardiovascular risk factors, including BP, dyslipidemia, and diabetes, before NCS.
B
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  • Management of hypertension

  • Management of beta-blockers

  • Management of RAAS inhibitors inhibitors

  • Management of RAAS inhibitors

  • Management of statins

  • Management of antiplatelets

  • Management of anticoagulants (general principles)

  • Management of anticoagulants (VKAs, elective surgeries/procedures)

  • Management of anticoagulants (VKAs, minor procedures)

  • Management of anticoagulants (heparins)

  • Management of anticoagulants (DOACs)

  • Management of diuretics

  • Management of SGLT-2 inhibitors

  • Prophylactic beta-blockers

  • Prophylactic alpha-2 agonists

  • Prophylactic CCBs

  • Prophylactic statins

  • Prophylactic aspirin

  • Prophylactic tranexamic acid

Nonpharmacologic interventions

Smoking cessation: as per ESC 2022 guidelines, advise smoking cessation > 4 weeks before NCS to reduce postoperative complications and mortality.
B
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Therapeutic procedures

Pulmonary artery catheterization
As per ACC/ACS/AHA/…/SVM 2024 guidelines:
Do not perform pulmonary artery catheterization routinely to reduce morbidity or mortality in patients with CVD undergoing NCS.
D
Consider performing pulmonary artery catheterization in patients with CVD undergoing NCS when underlying medical conditions significantly affecting hemodynamics (such as decompensated HF, severe valvular disease, combined shock states, pulmonary hypertension) cannot be corrected before surgery.
C
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  • Mechanical circulatory support

Perioperative care

Choice of anesthesia
As per ACC/ACS/AHA/…/SVM 2024 guidelines:
Consider administering either a volatile-based anesthetic agent or total IV anesthesia for general anesthesia in patients undergoing NCS, with no apparent difference in associated cardiovascular events (myocardial infarction, ischemia).
B
Consider administering either neuraxial or general anesthesia in patients undergoing NCS where neuraxial is feasible, with no apparent difference in associated cardiovascular events.
C
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  • Hemodynamic monitoring

  • BP control

  • Body temperature control

  • Thromboprophylaxis

  • Bleeding control

  • Pain management

Surgical interventions

Choice of surgical approach: as per ESC 2022 guidelines, consider using endovascular or video-assisted approaches in patients with high cardiovascular risk undergoing vascular or pulmonary surgery.
C
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Specific circumstances

Patients with obesity
As per ESC 2022 guidelines:
Assess cardiorespiratory fitness to estimate perioperative cardiovascular risk in patients with obesity, with particular attention to patients undergoing intermediate- and high-risk NCS.
B
Consider obtaining additional specialist assessment before major elective NCS in patients at high risk of obesity hypoventilation syndrome.
C
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  • Patients with diabetes mellitus

  • Patients with renal impairment

  • Patients with iron deficiency anemia

  • Patients with ACS

  • Patients with coronary artery disease (management of antiplatelets)

  • Patients with coronary artery disease (coronary artery revascularization)

  • Patients after PCI (management of antiplatelets)

  • Patients after PCI (timing of surgery)

  • Patients with HF

  • Patients with pulmonary hypertension

  • Patients with AAA

  • Patients with PAD

  • Patients with valvular heart disease (general principles)

  • Patients with valvular heart disease (aortic stenosis)

  • Patients with valvular heart disease (MS)

  • Patients with valvular heart disease (aortic regurgitation)

  • Patients with valvular heart disease (MR)

  • Patients with supraventricular arrhythmias

  • Patients with ventricular arrhythmias

  • Patients with cardiac implantable electronic devices

  • Patients with cardiomyopathy

  • Patients with pericardial diseases

  • Patients with adult congenital heart disease

  • Patients with patent foramen ovale

  • Patients with carotid artery disease (preoperative evaluation)

  • Patients with carotid artery disease (preoperative statins and antithrombotics)

  • Patients with carotid artery disease (carotid revascularization)

  • Patients with stroke

Patient education

General counseling
As per ESC 2022 guidelines:
Provide patients with individualized instructions for preoperative and postoperative changes in medications, in verbal and written formats with clear and concise directions.
B
Consider providing a structured information list (such as a checklist to help with common issues) in patients with CVD or at high risk of cardiovascular complications scheduled for NCS.
C
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Follow-up and surveillance

Postoperative cardiac monitoring, general principles
As per ESC 2022 guidelines:
Ensure high awareness of perioperative cardiovascular complications and obtain surveillance for perioperative myocardial infarction in patients undergoing intermediate- or high-risk NCS.
B
Obtain systematic perioperative myocardial infarction evaluation to identify the underlying pathophysiology and define therapy.
B
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  • Postoperative cardiac monitoring (ECG)

  • Postoperative cardiac monitoring (troponin)

  • Management of postoperative complications (myocardial injury/ischemia)

  • Management of postoperative complications (arrhythmias)

  • Management of postoperative complications (PE)