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.
