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Initial Assessment (ACC/AHA 2014)

  1. Determine timing of proposed surgery (emergency, urgent, time-sensitive, or elective – see Table 10-1) and risk of operation for major adverse cardiac event (MACE); divide risk of operation into two categories, low risk (risk of MACE <1%) or elevated risk (risk of MACE >1%); MACE is defined as death or myocardial infarction

  2. Use a risk calculator to more precisely calculate surgical risk; options include the revised cardiac risk index (RCRI), Gupta perioperative cardiac risk, or American College of Surgeons NSQIP risk calculator

  3. Assess patient's risk factors; for patients with valvular heart disease, obtain a preoperative echocardiogram if it has not been performed within the past 1 year or if there has been a significant change in clinical status

  4. Assess functional capacity; if the patient can perform at least 4 METS of work (walk two blocks on level ground, or carry two bags of groceries up one flight of stairs, without symptoms consistent with typical angina), they can proceed to surgery without further testing, even if they have elevated risk; if unable to perform 4 METS of work, do further cardiac workup if this will impact patient/clinician decision making; if patient willing to undergo PCI or CABG, then perform pharmacologic stress testing

  5. Adjunctive assessments

    1. 12 lead electrocardiogram

      1. Reasonable in patients with known heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease except for those undergoing low-risk surgery

      2. Routine ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures

    2. Assessment of left ventricular function

      1. Reasonable in patients with dyspnea of unknown origin or patients with known heart failure with worsening dyspnea

    3. Exercise testing

      1. Reasonable to forgo exercise testing and cardiac imaging in a patient with elevated risk but excellent functional capacity, >10 METS

      2. For those patients with functional capacity >4 METS–10 METS, it is reasonable to forgo exercise testing and cardiac imaging

      3. If <4 METS or unknown functional capacity, it is reasonable to perform exercise testing with cardiac imaging if it will change perioperative management

Medical Management (ACC/AHA 2014)

  1. Timing of surgery in patients with previous PCI

    1. Delay elective noncardiac surgery:

      1. 14 days after balloon angioplasty

      2. 30 days after bare-metal stent placement

      3. 365 days after drug-eluting stent placement

  2. Perioperative beta blocker therapy

    1. Continue beta blockers for those patients who have been taking them chronically prior to surgery

    2. Do not initiate beta blockers on the day of surgery

    3. Consider starting beta blockers at least 2 days prior to surgery in patients with intermediate or high risk of myocardial ischemia noted on preoperative evaluation, or three or more risk factors (diabetes, heart failure, CAD, renal insufficiency, cerebrovascular disease)

  3. Perioperative statin therapy

    1. Continue statins in patients who have been taking them chronically

    2. Consider initiating statins for patient undergoing vascular surgery

  4. Perioperative alpha-2 agonists

    1. Do not use for prevention of cardiac events in patients undergoing noncardiac surgery

  5. Perioperative angiotensin-converting enzyme inhibitors

    1. It is reasonable to ...

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