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Preoperative cardiac risk assessment for noncardiac surgery
1Cardiac Unit, Massachusetts General Hospital, Boston 02114, USA.
Insights
Preoperative cardiac risk stratification is crucial for patients undergoing noncardiac surgery. Careful assessment helps manage perioperative complications and improve long-term survival outcomes.
Area of Science:
- Cardiology
- Perioperative Medicine
- Surgical Risk Assessment
Background:
- Preoperative cardiac risk stratification is essential for patients undergoing noncardiac surgery.
- This assessment impacts both perioperative outcomes and long-term patient survival.
Purpose of the Study:
- To outline a strategy for preoperative cardiac risk stratification in patients undergoing noncardiac surgery.
- To identify appropriate noninvasive testing and treatment options for high-risk patients.
Main Methods:
- Initial clinical evaluation followed by noninvasive testing for selected patients.
- Utilizing exercise stress testing to assess for inducible ischemia.
- Employing dipyridamole thallium scintigraphy for patients unable to exercise adequately.
Main Results:
- Patients without significant inducible ischemia at high workload have low perioperative cardiac risk.
- Dipyridamole thallium scintigraphy is a validated alternative for exercise-intolerant patients.
- High-risk clinical profiles or significant thallium redistribution warrant consideration for coronary angiography.
Conclusions:
- Patients with high-risk profiles or significant test findings may require coronary angiography.
- Management options for high-risk patients include proceeding with surgery, revascularization, alternative surgery, or conservative therapy.
Abstract:
Patients presenting for noncardiac surgery should receive careful preoperative cardiac risk stratification. This has implications not only for the perioperative period, but also for long-term survival. After an initial clinical evaluation, certain patients will be referred for noninvasive testing. Those without significant inducible ischemia at a high workload have a low risk for perioperative cardiac complications. Patients who are unable to exercise adequately may require alternative forms of testing, of which dipyridamole thallium scintigraphy is the most thoroughly studied and validated option. Patients with either high-risk clinical profiles or significant thallium redistribution merit consideration for preoperative coronary angiography. Treatment options for high-risk patients include: (1) Proceeding with surgery as planned along with aggressive perioperative monitoring and anti-ischemic therapy, (2) coronary angiography with subsequent myocardial revascularization as appropriate before elective surgery, (3) selecting an alternative, lower risk surgical approach, and (4) cancellation of surgery in lieu of a trial of conservative therapy.