Perioperative cardiovascular assessment of patients undergoing noncardiac surgery

Preoperative assessment of the cardiac patient before noncardiac surgery is common in the clinical practice of the medical consultant, anesthesiologist, and surgeon. Currently, most noncardiac surgical procedures are performed for patients of advanced age, and the number of such surgeries is likely to increase with the aging of the population. These same patients have an increased prevalence of cardiovascular disease, especially ischemic heart disease, which is the primary cause of perioperative morbidity and mortality associated with noncardiac surgery. Since 1996, 3 American College of Cardiology/American Heart Association guideline documents have been published, each reflecting the available literature, with recommendations for the preoperative cardiovascular evaluation and treatment of the patient undergoing noncardiac surgery. Our review describes the 2007 American College of Cardiology/American Heart Association guidelines, the most recent revision, focusing on a newly recommended 5-step algorithmic approach to managing this clinical problem, particularly for the patient with known or suspected coronary heart disease. Continued emphasis should be given to preoperative clinical risk stratification, with noninvasive testing reserved for those patients in whom a substantial change in medical management would be anticipated based on results of testing. Pharmacologic therapy holds more promise than coronary revascularization for the reduction of major adverse perioperative cardiac events that might complicate noncardiac surgery.