CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
The POISE-3 Trial
In this international, randomized, controlled trial, investigators studied 9535 patients (mean age 69.4 years, 44% females) undergoing non-cardiac surgery (77% non-orthopedic). Read More
This chapter provides an overview of the perioperative evaluation of cardiovascular disease in patients undergoing noncardiac surgery. The cornerstone of this evaluation is a history and physical examination focused on establishing the temporal urgency of a procedure or surgery, a patient’s functional status, and whether there are any signs or symptoms possibly of cardiac origin (see Fuster and Hurst’s Central Illustration). Perioperative risk stratification depends on the inherent risk associated with a planned surgery and the risk ascribed to patient specific conditions. Risk stratification algorithms include the Revised Cardiac Risk Index and the National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator. The underlying philosophy of preoperative testing should be guided by whether results of testing would change management outside of the context of the surgery planned. Prophylactic coronary revascularization has not been associated with improved outcomes. Considerations about medical therapy in the perioperative setting include decisions about ß-blockade, antiplatelet treatments, and statin medications. A thorough perioperative evaluation is a critical component of the preparation for noncardiac surgery and offers an opportunity to elucidate cardiac symptoms and optimize medical therapies in the context of the planned surgery.
eFig 72-01 Chapter 72: Perioperative Evaluation for Noncardiac Surgery
The perioperative evaluation of cardiovascular disease in patients undergoing noncardiac surgery remains a subject of much research and debate. The desire to optimally manage these patients is often confused with “cardiac clearance,” but this term fails to capture the complexity of care. As with most clinical scenarios, the cornerstone of good perioperative management is a conscientious history and physical exam. Understanding a patient’s functional status and carefully establishing whether a patient is experiencing any cardiac signs or symptoms are of paramount importance in guiding management decisions. As in the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Society of Anesthesiology (ESA) guidelines,1,2 the best clinical approach to evaluating cardiac disease in patients prior to surgery is in the framework of whether the cardiac disease is active or stable while understanding the urgency and risk of the operation needed. A summary of our global approach to perioperative evaluation and management may be found in Figs. 72–1 and 72–2.1
Summary algorithm for the cardiac evaluation and management of patients prior to noncardiac surgery from the 2014 ACC/AHA Clinical Practice Guidelines. ACS, acute coronary syndrome; CAD, coronary artery disease; CPGs, clinical practice guidelines; GDMT, guideline-directed medical therapy; MACE, major adverse cardiac event; METs, metabolic equivalents; NB, no benefit. Reproduced with permission from Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline ...