Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review

JAMA. 2020 Jul 21;324(3):279-290. doi: 10.1001/jama.2020.7840.

Abstract

Importance: Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery.

Observations: Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose β-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without β-blocker use; P = .005) and mortality (3.1% vs 2.3% without β-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration.

Conclusions and relevance: Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.

Publication types

  • Research Support, N.I.H., Extramural
  • Review

MeSH terms

  • Adrenergic beta-Antagonists / administration & dosage
  • Adrenergic beta-Antagonists / adverse effects
  • Age Factors
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Anticoagulants / administration & dosage
  • Anticoagulants / adverse effects
  • Aspirin / administration & dosage
  • Aspirin / adverse effects
  • Biomarkers / blood
  • Cardiovascular Diseases / etiology*
  • Coronary Angiography
  • Echocardiography, Transesophageal
  • Electrocardiography / methods
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / adverse effects
  • Heart Failure / diagnosis
  • Heart Valve Diseases / diagnosis
  • Humans
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use
  • Middle Aged
  • Myocardial Infarction / diagnosis
  • Myocardial Infarction / etiology
  • Myocardial Ischemia / diagnosis
  • Myocardial Revascularization
  • Postoperative Complications / etiology*
  • Postoperative Complications / prevention & control
  • Preoperative Care / methods
  • Risk Assessment / methods*
  • Stents / adverse effects
  • Stroke / chemically induced
  • Surgical Procedures, Operative / adverse effects*
  • Time Factors
  • United States / epidemiology

Substances

  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Anticoagulants
  • Biomarkers
  • Fibrinolytic Agents
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors
  • Aspirin