Elsevier

Mayo Clinic Proceedings

Volume 96, Issue 8, August 2021, Pages 2260-2276
Mayo Clinic Proceedings

Thematic review on perioperative medicine
Perioperative Cardiac Risk Reduction in Noncardiac Surgery

https://doi.org/10.1016/j.mayocp.2021.03.014Get rights and content

Abstract

Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of—and intervention for—any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.

Section snippets

Ischemic Heart Disease

Ischemic heart disease is associated with an increased risk of MACE in the perioperative setting, and this risk proportionally increases with the severity of IHD.7 Management of IHD is different, based on whether the patient has an acute coronary syndrome (ACS) or chronic IHD. Patients with ACS, defined as unstable angina or myocardial infarction (MI), should have noncardiac surgery delayed until the ACS is appropriately managed. A number of options are available for managing ACS including

Timing of Noncardiac Surgery after MI or Revascularization

For patients with recent MIs, the most effective way to mitigate risk of further MACE is to increase the interval between the MI and the noncardiac surgery. Delaying surgery for 60 days following MI decreases the perioperative risk substantially. This risk continues to decrease as the duration of time separating MI and noncardiac surgery increases.5 These data were reported in a retrospective analysis of more than 500,000 patients undergoing noncardiac surgery. Compared with controls, patients

Patients Needing Revascularization

Patients who had MIs before noncardiac surgery, and underwent revascularization with either CABG or PCI/stenting before noncardiac surgery, had significant decreases in the rate of postoperative reinfarction compared with those who were not revascularized (5.1% vs 10%). A 30-day and 1-year mortality benefit was also demonstrated.8 This benefit is only realized if the noncardiac surgery was at least 30 days after the MI, regardless of revascularization status. For patients who had MIs 2 to 3

Myocardial Injury After Noncardiac Surgery

Over the past few years, MINS has been associated with increased cardiovascular morbidity and mortality in the perioperative period. In a large prospective international cohort study of more than 15,000 patients aged 45 years and older who underwent inpatient noncardiac surgery, MINS (peak troponin T of ≥ 0.04 ng/L judged to be caused by myocardial ischemia within the first 72 hours postoperation) was detected in 8% of all patients.12 Of the patients who were diagnosed with MINS, the vast

Heart Failure

Heart failure has been recognized as a significant risk factor for perioperative major adverse cardiac events and increased mortality, independent of the presence of IHD.5 The perioperative mortality risk in patients with HF is 2-fold to 4-fold higher compared with patients who have isolated CAD.17 Heart failure is associated with increased risk of complications in low- as well as medium- and high-risk surgeries. In addition, HF strongly predicts serious noncardiac-related postoperative events

Perioperative Arrhythmias

Arrhythmias are relatively common in the perioperative setting, occurring in an estimated 11% of patients undergoing general anesthesia.5,43,44 The perioperative setting is arrhythmogenic because of the effects of multiple factors including altered autonomic tone with sympathetic activation being predominant, hemodynamic instability (hypovolemia as well as positive fluid balance), hypoxia, and the metabolic stressors encountered during this period such as acid-base abnormalities (acidemia) as

Supraventricular Arrhythmia

Supraventricular tachycardias (SVTs) are the most common type of arrhythmia, occurring in 7.6% of patients undergoing noncardiac surgery,45,46 with atrial fibrillation (AF) being the most common pathologic SVT.5,47 The major risk factors for SVTs are male sex, age greater than 70; White race; significant valvular disease; history of comorbid medical conditions (especially arrhythmia, congestive HF, or hypertension); elevated preoperative BNP or NT-proBNP; and higher-risk surgery with vascular,

Atrial Fibrillation

Atrial fibrillation can be identified at any stage of the surgical episode of care. Often, AF is identified as part of the preoperative evaluation; however, it can develop intraoperatively and postoperatively as well. When AF is identified preoperatively, and is a new diagnosis, many experts suggest that it is prudent to defer surgery until this can be evaluated further, as there may be an associated underlying condition that might increase perioperative risk such as hyperthyroidism,

Ventricular Arrhythmia

Frequent premature ventricular contractions (PVCs) and nonsustained ventricular tachycardia noted in the preoperative period are associated with increased risk of arrhythmia in the perioperative period, but the risk of major adverse cardiac events (cardiac death and nonfatal MI) has not been noted to be elevated.56,57 In an observational study of 412 patients undergoing noncardiac surgery, nonsustained ventricular tachycardia occurred in 15% of patients but had no effect on 30-day outcome.58 In

Bradyarrhythmias

Disorders of conduction have the potential to progress to complete heart block, which has been associated with increased morbidity and mortality in the perioperative period. Fortunately, with adequate monitoring and caution with medications that slow conduction at the atrioventricular node further, such as beta blockers, the incidence of this progression has been relatively low.61, 62, 63 For patients who develop bradyarrhythmia in the postoperative period, the recommended acute treatment is

Medications With Antiplatelet Activity

Antiplatelet agents are commonly encountered in the perioperative setting, as they are frequently used for the treatment of pain and also as a cornerstone of primary and secondary risk reduction for coronary thrombotic events. In general, management of antiplatelet agents in the perioperative period involves a risk–benefit analysis, weighing the risk of procedural bleeding against the benefit of preventing thrombotic events.

Conclusion

Cardiovascular complications remain a major source of morbidity and mortality in the perioperative setting. Three comprehensive consensus guidelines have been published by American, European, and Canadian cardiology and anesthesiology societies, outlining the evidence existing at the time, and make recommendations for care of patients in the perioperative period. However, since publication of these guidelines, the medical data and knowledge base has evolved. The most recent advances in medical

References (96)

  • S. Venkatesan et al.

    Cohort study of preoperative blood pressure and risk of 30-day mortality after elective non-cardiac surgery

    Br J Anaesth

    (2017)
  • C. Prys-Roberts et al.

    Studies of anaesthesia in relation to hypertension: I. cardiovascular responses of treated and untreated patients

    Br J Anaesth

    (1971)
  • N. Weksler et al.

    The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery?

    J Clin Anesth

    (2003)
  • R.D. Sanders et al.

    Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery

    Br J Anaesth

    (2019)
  • T.J. Gal et al.

    Hypertension in the immediate postoperative period

    Br J Anaesth

    (1975)
  • W. Johnson et al.

    Hypertension crisis in the emergency department

    Cardiol Clin

    (2012)
  • A.M. Stewart et al.

    Supraventricular tachyarrhythmias and their management in the perioperative period

    Contin Educ Anaesth Crit Care Pain

    (2015)
  • A.A. Vaporciyan et al.

    Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients

    J Thorac Cardiovasc Surg

    (2004)
  • H.F. Groenveld et al.

    Rate control efficacy in permanent atrial fibrillation: successful and failed strict rate control against a background of lenient rate control: data from RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation)

    J Am Coll Cardiol

    (2013)
  • P.D. Bhave et al.

    Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery

    Am Heart J

    (2012)
  • J.H. Butt et al.

    Risk of thromboembolism associated with atrial fibrillation following noncardiac surgery

    J Am Coll Cardiol

    (2018)
  • I.M. Danelich et al.

    Practical management of postoperative atrial fibrillation after noncardiac surgery

    J Am Coll Surg

    (2014)
  • C.T. January et al.

    2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society

    J Am Coll Cardiol

    (2014)
  • A. Zimmermann et al.

    Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice

    J Vasc Surg

    (2018)
  • D.H. Stone et al.

    Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery

    J Vasc Surg

    (2011)
  • A.J. Hui et al.

    Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases

    Gastrointest Endosc

    (2004)
  • J. Katz et al.

    Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery

    Ophthalmology

    (2003)
  • A. Ockerman et al.

    Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis

    Int J Oral Maxillofac Surg

    (2020)
  • R. Moreno et al.

    Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies

    J Am Coll Cardiol

    (2005)
  • P.G. Chassot et al.

    Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction

    Br J Anaesth

    (2007)
  • D.E. Winchester et al.

    Evidence of pre-procedural statin therapy a meta-analysis of randomized trials

    J Am Coll Cardiol

    (2010)
  • S. Kheterpal et al.

    Chronic angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy combined with diuretic therapy is associated with increased episodes of hypotension in noncardiac surgery

    J Cardiothorac Vasc Anesth

    (2008)
  • N.A. Khan et al.

    Risk of intraoperative hypotension with loop diuretics: a randomized controlled trial

    Am J Med

    (2010)
  • C. Álvarez Zurro et al.

    High levels of preoperative and postoperative N terminal B-type natriuretic propeptide influence mortality and cardiovascular complications after noncardiac surgery: a prospective cohort study

    Eur J Anaesthesiol

    (2016)
  • N.R. Smilowitz et al.

    Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery

    JAMA Cardiol

    (2017)
  • S.D. Kristensen et al.

    2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA)

    Eur J Anaesthesiol

    (2014)
  • S.D. Paul et al.

    Concordance of preoperative clinical risk with angiographic severity of coronary artery disease in patients undergoing vascular surgery

    Circulation

    (1996)
  • M. Livhits et al.

    Risk of surgery following recent myocardial infarction

    Ann Surg

    (2011)
  • G.N. Levine et al.

    2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

    Circulation

    (2016)
  • S.H. Yin et al.

    Duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent: systematic review and network meta-analysis

    BMJ

    (2019)
  • F. Botto et al.

    Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes

    Anesthesiology

    (2014)
  • S. De Hert et al.

    Pre-operative evaluation of adults undergoing elective noncardiac surgery: updated guideline from the European Society of Anaesthesiology

    Eur J Anaesthesiol

    (2018)
  • P.J. Devereaux et al.

    Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study

    Ann Intern Med

    (2011)
  • A. Foucrier et al.

    The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery

    Anesth Analg

    (2014)
  • S. van Diepen et al.

    Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients

    Circulation

    (2011)
  • B.J. Lerman et al.

    Association of left ventricular ejection fraction and symptoms with mortality after elective noncardiac surgery among patients with heart failure

    JAMA

    (2019)
  • A. Nicoara et al.

    Diastolic dysfunction, diagnostic and perioperative management in cardiac surgery

    Curr Opin Anaesthesiol

    (2015)
  • P.S. Roshanov et al.

    Withholding versus continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers before noncardiac surgery: an analysis of the vascular events in noncardiac surgery patients cohort evaluation prospective cohort

    Anesthesiology

    (2017)

    • Potential Competing Interests: The authors report no competing interests.

    View full text
    © 2021 Mayo Foundation for Medical Education and Research