New ACC/AHA Guidelines on Perioperative CV Evaluation for Noncardiac Surgery

New ACC/AHA Guidelines on Perioperative CV Evaluation for Noncardiac Surgery


Medscape Medical News 2007


Study Highlights


Clinical trial evidence shows a protective effect of perioperative statin use on cardiac complications during noncardiac surgery, so statins should not be discontinued before surgery. Optimal dose, target or achieved levels of low-density lipoprotein cholesterol, and indications for therapy are still unclear.


For emergency noncardiac surgery, preoperative heart testing should not be done; rather, the patient should immediately undergo the emergency procedure.
Patients with severe or symptomatic cardiovascular disease and/or active cardiac conditions should undergo evaluation and treatment before noncardiac surgery. These conditions include unstable coronary syndromes, blockage of 2 or more coronary vessels, decompensated heart failure, significant cardiac arrhythmias, or severe valvular disease.


For high-risk cardiac patients undergoing noncardiac surgery, successful perioperative evaluation and management require multidisciplinary management and communication among the surgeon, anesthesiologist, primary caregiver, and cardiovascular consultant.


Noninvasive and invasive preoperative cardiac testing should not be done unless results will affect patient management.


Most patients with asymptomatic heart disease can safely undergo elective noncardiac surgery without first requiring angioplasty or coronary bypass grafting to lower the risk for surgery.


Angioplasty with stenting in patients who are asymptomatic may even increase the risk for perioperative cardiovascular complications, such as myocardial infarction, for which risk increases 4 to 6 weeks after stenting. For that reason, patients with stents should receive antiplatelet therapy for 4 to 6 weeks after stenting or for up to 1 year for coated or drug-eluting stents.


Patients who require cardiac intervention before elective noncardiac surgery should have angioplasty with use of a bare-metal stent followed by 4 to 6 weeks of thienopyridine plus aspirin.


Because of recent evidence suggesting that surgical outcomes in asymptomatic patients without active cardiac conditions is similar whether cardiovascular interventions are performed, preoperative cardiac screening is not recommended in these patients.


The previous guidelines advocated discontinuing antiplatelet agents before surgery to reduce risks for excessive bleeding associated with any surgical procedure. The updated guidelines recommend stopping antiplatelet medication for as short a time as possible after stent placement.


For patients who already have a drug-eluting coronary stent and require emergent noncardiac surgery, aspirin therapy should be continued if possible and prescription agents resumed as soon as possible.


Indications for further cardiac evaluation and therapy are the same in the noncardiac-surgery perioperative period as in the nonoperative setting, but timing of these interventions depends on several factors, such as the urgency of noncardiac surgery, patient-specific risk factors, and the degree of risk linked with the noncardiac procedure.


For many patients, noncardiac surgery is the first opportunity to evaluate short-term and long-term cardiac risk. Therefore, the cardiac consultant should make recommendations that should reduce immediate perioperative cardiac risk and to determine the need for subsequent postoperative risk stratification and interventions to modify cardiovascular risk factors.


Future research should address the value of routine prophylactic medical therapy vs more extensive diagnostic evaluation and interventions.


Pearls for Practice


Patients with severe or symptomatic cardiovascular disease and/or active cardiac conditions should undergo evaluation and treatment before noncardiac surgery. Statins should not be discontinued before surgery. Patients who require cardiac intervention before elective noncardiac surgery should have angioplasty with use of a bare-metal stent followed by 4 to 6 weeks of thienopyridine plus aspirin.


Most patients with asymptomatic heart disease can safely undergo elective noncardiac surgery without first requiring angioplasty or coronary bypass grafting to lower the risk for surgery. Noninvasive and invasive preoperative cardiac testing should not be performed unless results will affect patient management.