Management of cardiac risk for noncardiac surgery
- PJ Devereaux, MD, PhD
PJ Devereaux, MD, PhD
- Associate Professor of Medicine, Division of Cardiology
- McMaster University
- Steven L Cohn, MD, FACP, SFHM
Steven L Cohn, MD, FACP, SFHM
- Professor of Clinical Medicine
- University of Miami Miller School of Medicine
- Kim A Eagle, MD, MACC
Kim A Eagle, MD, MACC
- Albion Walter Hewlett Professor of Internal Medicine
- University of Michigan
- Section Editors
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
- Allan S Jaffe, MD
Allan S Jaffe, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Mayo Medical School
Cardiovascular complications, such as myocardial infarction, heart failure, or death attributable to coronary heart disease, pose some of the most significant risks to patients undergoing major noncardiac surgery. This topic will discuss potential interventions to reduce this risk in patients at relatively high baseline risk. The following issues of relevance to patients undergoing noncardiac surgery are discussed separately:
●The estimation of baseline risk (see "Evaluation of cardiac risk prior to noncardiac surgery")
●The approach to perioperative myocardial infarction (see "Perioperative myocardial infarction after noncardiac surgery")
●The perioperative evaluation and management of heart failure (see "Management of perioperative heart failure in patients undergoing noncardiac surgery")
●Noncardiac surgery in patients with valvular heart disease (see "Noncardiac surgery in patients with aortic stenosis" and "Noncardiac surgery in patients with mitral or aortic regurgitation")
- Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
- Palda VA, Detsky AS. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med 1997; 127:313.
- Fleisher LA, Eagle KA. Clinical practice. Lowering cardiac risk in noncardiac surgery. N Engl J Med 2001; 345:1677.
- Monaco M, Stassano P, Di Tommaso L, et al. Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective, randomized study. J Am Coll Cardiol 2009; 54:989.
- McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004; 351:2795.
- Garcia S, Moritz TE, Goldman S, et al. Perioperative complications after vascular surgery are predicted by the revised cardiac risk index but are not reduced in high-risk subsets with preoperative revascularization. Circ Cardiovasc Qual Outcomes 2009; 2:73.
- Garcia S, Moritz TE, Ward HB, et al. Usefulness of revascularization of patients with multivessel coronary artery disease before elective vascular surgery for abdominal aortic and peripheral occlusive disease. Am J Cardiol 2008; 102:809.
- Domanski M, Ellis S, Eagle K. Does preoperative coronary revascularization before noncardiac surgery reduce the risk of coronary events in patients with known coronary artery disease? Am J Cardiol 1995; 75:829.
- Rihal CS, Eagle KA, Mickel MC, et al. Surgical therapy for coronary artery disease among patients with combined coronary artery and peripheral vascular disease. Circulation 1995; 91:46.
- Eagle KA, Rihal CS, Mickel MC, et al. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation 1997; 96:1882.
- Hertzer NR, Young JR, Beven EG, et al. Late results of coronary bypass in patients with peripheral vascular disease. I. Five-year survival according to age and clinical cardiac status. Cleve Clin Q 1986; 53:133.
- Hertzer NR, Young JR, Beven EG, et al. Late results of coronary bypass in patients with peripheral vascular disease. II. Five-year survival according to sex, hypertension, and diabetes. Cleve Clin J Med 1987; 54:15.
- Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996; 335:1713.
- Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology 1998; 88:7.
- Stone JG, Foëx P, Sear JW, et al. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology 1988; 68:495.
- Bodenheimer MM. Noncardiac surgery in the cardiac patient: what is the question? Ann Intern Med 1996; 124:763.
- POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371:1839.
- Bouri S, Shun-Shin MJ, Cole GD, et al. Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart 2014; 100:456.
- Bangalore S, Wetterslev J, Pranesh S, et al. Perioperative beta blockers in patients having non-cardiac surgery: a meta-analysis. Lancet 2008; 372:1962.
- Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 331:313.
- Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:2406.
- Blessberger H, Kammler J, Domanovits H, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev 2014; :CD004476.
- Dunkelgrun M, Boersma E, Schouten O, et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann Surg 2009; 249:921.
- Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2246.
- Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005; 353:349.
- London MJ, Hur K, Schwartz GG, Henderson WG. Association of perioperative β-blockade with mortality and cardiovascular morbidity following major noncardiac surgery. JAMA 2013; 309:1704.
- Friedell ML, Van Way CW 3rd, Freyberg RW, Almenoff PL. β-Blockade and Operative Mortality in Noncardiac Surgery: Harmful or Helpful? JAMA Surg 2015; 150:658.
- Jørgensen ME, Hlatky MA, Køber L, et al. β-Blocker-Associated Risks in Patients With Uncomplicated Hypertension Undergoing Noncardiac Surgery. JAMA Intern Med 2015; 175:1923.
- Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA 2002; 287:1435.
- Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ 2005; 331:932.
- Wallace AW, Au S, Cason BA. Perioperative β-blockade: atenolol is associated with reduced mortality when compared to metoprolol. Anesthesiology 2011; 114:824.
- Mashour GA, Sharifpour M, Freundlich RE, et al. Perioperative metoprolol and risk of stroke after noncardiac surgery. Anesthesiology 2013; 119:1340.
- Ashes C, Judelman S, Wijeysundera DN, et al. Selective β1-antagonism with bisoprolol is associated with fewer postoperative strokes than atenolol or metoprolol: a single-center cohort study of 44,092 consecutive patients. Anesthesiology 2013; 119:777.
- Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006; 113:1361.
- Landesberg G, Mosseri M, Zahger D, et al. Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 2001; 37:1839.
- Feringa HH, Bax JJ, Boersma E, et al. High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation 2006; 114:I344.
- American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Society of Echocardiography, American Society of Nuclear Cardiology, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. J Am Coll Cardiol 2009; 54:2102.
- Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383.
- Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370:1494.
- Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257:399.
- Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355:1295.
- Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth 2010; 104:305.
- Gerstein NS, Schulman PM, Gerstein WH, et al. Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg 2012; 255:811.
- Nishina K, Mikawa K, Uesugi T, et al. Efficacy of clonidine for prevention of perioperative myocardial ischemia: a critical appraisal and meta-analysis of the literature. Anesthesiology 2002; 96:323.
- Wallace AW, Galindez D, Salahieh A, et al. Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Anesthesiology 2004; 101:284.
- Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014; 370:1504.
- Sardella G, Lucisano L, Mancone M, et al. Comparison of high reloading ROsuvastatin and Atorvastatin pretreatment in patients undergoing elective PCI to reduce the incidence of MyocArdial periprocedural necrosis. The ROMA II trial. Int J Cardiol 2013; 168:3715.
- Di Sciascio G, Patti G, Pasceri V, et al. Efficacy of atorvastatin reload in patients on chronic statin therapy undergoing percutaneous coronary intervention: results of the ARMYDA-RECAPTURE (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) Randomized Trial. J Am Coll Cardiol 2009; 54:558.
- Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004; 39:967.
- Lindenauer PK, Pekow P, Wang K, et al. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004; 291:2092.
- O'Neil-Callahan K, Katsimaglis G, Tepper MR, et al. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Cardiol 2005; 45:336.
- Schouten O, Hoeks SE, Welten GM, et al. Effect of statin withdrawal on frequency of cardiac events after vascular surgery. Am J Cardiol 2007; 100:316.
- Berwanger O, de Barros E Silva PG, Barbosa RR, et al. Atorvastatin for high-risk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial. Am Heart J 2017; 184:88.
- Berwanger O, Le Manach Y, Suzumura EA, et al. Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. Eur Heart J 2016; 37:177.
- London MJ, Schwartz GG, Hur K, Henderson WG. Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery. JAMA Intern Med 2017; 177:231.
- Antoniou GA, Hajibandeh S, Hajibandeh S, et al. Meta-analysis of the effects of statins on perioperative outcomes in vascular and endovascular surgery. J Vasc Surg 2015; 61:519.
- Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. Anesthesiology 2017; 126:16.
- Zhao N, Xu J, Singh B, et al. Nitrates for the prevention of cardiac morbidity and mortality in patients undergoing non-cardiac surgery. Cochrane Database Syst Rev 2016; :CD010726.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1082.
- Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol 2017; 33:17.
- PATIENTS WITH A RECENT ACUTE CORONARY SYNDROME
- PATIENTS WHO NEED URGENT OR EMERGENT SURGERY
- INITIAL RISK ASSESSMENT
- REVASCULARIZATION BEFORE SURGERY
- BETA BLOCKERS
- Patients without indications for long-term therapy
- Patients who may require preoperative initiation of therapy
- Patients taking beta blockers
- - Choice of agent
- - Baseline heart rate and blood pressure
- Recommendations of others
- OTHER MEDICAL THERAPIES
- Antiplatelet therapy
- ACE inhibitor or ARB
- Nitrate therapy
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS
- Angiography and revascularization
- Beta blockers
- Antiplatelet therapy