Noncardiac surgery in the patient with heart disease

Clinicians are increasingly asked what they can do to evaluate and lower the risk of perioperative cardiac complications. Approximately 4 decades ago, there were few tools to guide the evaluation of perioperative risk. The American Society of Anesthesiology Classification System (ASA class) gave only a vague idea of the risk patients faced during surgery, but the modern era of clinical risk assessment for perioperative complications has seen the introduction of tools that allow clinicians to estimate risk, and also the addition of stress testing for assessing perioperative risk. None of these tests, however, were designed to identify perioperative cardiac risk. This article reviews the literature on perioperative risk assessment, risk reduction, and testing modalities in patients with cardiac disease, along with the role of perioperative angioplasty and the current American College of Cardiology/American Heart Association guidelines.