Perioperative Evaluation and Management for Noncardiac Surgery

Andrei Brateanu

RAPID BOARD REVIEW—KEY POINTS TO REMEMBER:

Cardiovascular Risk Assessment

The stepwise approach to preoperative cardiac assessment

Patients that require emergency surgery do not need preoperative evaluation.
Patients that do not require emergency surgery should be evaluated and treated for
- Unstable coronary syndromes
- Decompensated or new-onset congestive heart failure (CHF)
- Arrhythmias
- Severe valvular disease
Patients should be stratified based on the cardiac risk associated with the surgical procedures:
- High cardiac risk (>5%)
- Intermediate cardiac risk (1% to 5%)
- Low cardiac risk (<1%)
Patients undergoing low cardiac risk procedures do not require further evaluation.
Patients at intermediate to high cardiac risk should have their functional capacity assessed.

Patients that are able to perform more than 4 metabolic equivalent of tasks (METs) without symptoms can proceed to surgery without further cardiac evaluation.
Patients having symptoms, or with low (<4 METs) or unknown functional capacity status should have the cardiac risk assessed based on the following five risk factors:
- Ischemic heart disease
- Compensated CHF
- Diabetes mellitus
- Chronic kidney disease
- Cerebrovascular accident
Patients with no risk factors should proceed to surgery without further evaluation.
- Electrocardiogram does not have to be routinely performed in the perioperative period.
- Left ventricular function can be assessed in patients with dyspnea of unknown etiology or in CHF patients with worsening symptoms or changes in medical status.
- Noninvasive stress testing can be performed in patients with unreliable histories or poor functional capacity, or in patients scheduled for high- or intermediate-risk surgery when additional clinical risk factors are present. It should not be done in patients undergoing low-risk surgery. It should be avoided in high-risk patients with unstable myocardial ischemia, where coronary angiography is recommended.

Cardiovascular Risk Reduction

Coronary revascularization with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) in

Survivors of sudden cardiac death
ST segment elevation myocardial infarction (STEMI). Urgent CABG indicated in patients that are not candidates for PCI and have:
- Ongoing/recurrent ischemia
- Severe heart failure
- High-risk features
Non-STEMI with refractory angina, hemodynamic or electrical instability
Symptomatic stable ischemic heart disease (SIHD) with
- Significant unprotected left main coronary artery stenosis
- Three vessel disease with/without proximal left anterior descending (LAD) stenosis
- Two vessel disease with proximal LAD stenosis or extensive ischemia, especially in patients with left ventricular dysfunction and ejection fraction <50%

Pulmonary Risk Assessment

Evaluation not indicated in patients requiring emergency surgery.
Diagnostic spirometry indicated in all patients requiring elective resectional thoracic surgery. Carbon monoxide diffusing capacity (DLCO) required in patients having excessive dyspnea on exertion or evidence of interstitial lung disease on radiographs.
- If forced expiratory volume in one second (FEV1) ≥2 L or ≥80% predicted, pneumonectomy can be performed without further evaluation.
- If FEV1 ≥1.5 L, lobectomy can be performed.
- If FEV1 or DLCO is <80% predicted, additional testing should be done.
- If FEV1 or DLCO is <40% predicted, exercise testing is recommended.