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Perioperative cardiac risk assessment for noncardiac surgery
R H Mehta1, E Bossone, K A Eagle
1Division of Cardiology, University of Michigan, Ann Arbor, USA. rmehta@groupwise.med.umich.edu
Insights
Patients with coronary artery disease undergoing noncardiac surgery face cardiac risks. A simplified assessment stratifies patients into low, intermediate, and high risk groups to guide perioperative management and interventions.
Area of Science:
- Cardiology
- Perioperative Medicine
- Cardiac Surgery
Background:
- Patients with coronary artery disease (CAD) undergoing noncardiac surgery are at increased risk of perioperative cardiac complications.
- Accurate risk assessment is crucial for optimizing management in diverse surgical settings.
Purpose of the Study:
- To propose a simplified, stepwise approach for perioperative cardiac risk assessment in patients with CAD undergoing noncardiac surgery.
- To provide guidelines for risk stratification and management based on clinical data and surgical factors.
Main Methods:
- Risk assessment based on surgery urgency, type, patient history, physical examination, functional capacity, and prior procedures.
- Stratification into high, intermediate, and low risk groups for cardiac events.
- Recommendations for further cardiac evaluation (stress testing, cardiac catheterization) and intervention based on risk category and surgical invasiveness.
Main Results:
- A simplified approach identifies patients into low, intermediate, and high risk categories for perioperative cardiac events.
- Guidelines are provided for managing patients based on their risk stratification and the planned surgical procedure.
- Recommendations include proceeding with urgent surgeries with optimized management, avoiding further cardiac evaluation for low/intermediate risk minor surgery, and utilizing stress tests or cardiac catheterization for higher-risk scenarios.
Conclusions:
- A stepwise, simplified risk assessment strategy can effectively guide perioperative management for patients with CAD undergoing noncardiac surgery.
- This approach aims to reduce perioperative cardiac events through appropriate monitoring, risk modification (e.g., beta-blockers), and timely interventions.
- The proposed guidelines facilitate informed decision-making for surgeons and cardiologists, enhancing patient safety.
Abstract:
Patients with coronary artery disease who undergo noncardiac surgery are at risk of cardiac complications. It is, therefore, imperative to assess the risk of noncardiac surgery in these patients in a variety of operative settings. We propose a simplified approach at perioperative risk assessment that ascertains risks based on the need and urgency of surgery, and the type of surgery. Furthermore, we suggest guidelines for perioperative risk assessment based on patient's history and physical exam, their functional capacity and prior procedures. Based on these clinical data, we identify patients into three categories for a cardiac event during noncardiac surgery: high, intermediate and low risk groups. We recommend that all urgent surgeries should be carried out with attempts made at proper perioperative management to reduce the risk of cardiac events. Further, low or intermediate risk patients undergoing minor surgery should be operated without any further cardiac evaluation. Intermediate risk patients, who need an intermediate or major surgery, should undergo a stress test to evaluate for ischemia. If there is evidence of a large ischemic burden and those patients at high risk should undergo cardiac catheterization and appropriate intervention. We also suggest methods of modifying risk in the perioperative period for all patients to reduce perioperative cardiac events with proper monitoring and use of medications including beta blockers. This article provides a detailed review on the current literature supporting the stepwise approach proposed by us.