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Perioperative Cardiovascular Evaluation

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Key Points 1. The aims of preoperative evaluation in the patient undergoing noncardiac surgery are: a. assessment of perioperative risk (which can be used to inform the decision to proceed or the choice of surgery and which includes the patient's perspective), b. determination of the need for changes in management, and c. identification of cardiovascular conditions or risk factors requiring longer-term management. 2. A validated risk-prediction tool (e.g., ACS NSQIP risk calculator and Lee Revised Cardiac Risk Index) can be useful in predicting the risk of perioperative MACE in patients undergoing noncardiac surgery. 3. In the absence of a coronary intervention, ≥60 days should elapse after a myocardial infarction before noncardiac surgery is undertaken. 4. The decision to perform further cardiovascular testing depends upon the urgency of surgery, assessment of risk based upon the combination of surgical and clinical factors, and functional status. Risk is dichotomized into low (<1% incidence of MACE) and elevated risk. 5. Testing should only be performed if it changes management. 6. Elective noncardiac surgery should optimally be delayed 365 days after DES implantation. With the newer-generation DES, elective noncardiac surgery after DES implantation may be considered after 180 days if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis. 7. The only Class I indication for perioperative beta-blocker therapy is that therapy should be continued in patients undergoing surgery who have been on beta-blockade chronically. Active management of patients on beta blockers is required during and after surgery. Particular attention should be paid to the need to modify or temporarily discontinue beta blockers as clinical circumstances (e.g., hypotension, bradycardia, bleeding) dictate. 8. Management of the perioperative antiplatelet therapy should be determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient, who should weigh the relative risk of bleeding with that of stent thrombosis.

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