Cardiovascular disease is the leading cause of death in the United States. Of the 27 million patients who undergo non-cardiac surgery in the United States each year, approximately 8 million have coronary artery disease or risk factors for cardiovascular disease and 1 million have perioperative cardiac complications.1 Cardiovascular perioperative risk assessment has become a vital tool for evaluating patients prior to surgery to optimize their cardiovascular safety and initiate lifestyle modifications that coupled together provide short- and long-term benefits. The American College of Cardiology/American Heart Association (ACC/AHA) task force committee created guidelines for the perioperative risk assessment of cardiovascular disease for non-cardiac surgery to address this growing problem. Over the last 5 years new evidence has emerged resulting in an update of these guidelines in 2007.2
Goals of Preoperative Evaluation
As a physician evaluates a patient prior to non-cardiac surgery, several goals should be kept in mind:
Identify patients who are at risk for perioperative cardiac events.
Identify the risk of the proposed surgery (Table 16-1).
Identify active cardiovascular disease and clinical risk factors (Tables 16-2 and 16-3).
Identify patients at risk to develop cardiac events after discharge from the hospital.
Intervene to reduce perioperative morbidity and mortality or cancel the planned procedure.
Intervene to reduce long-term cardiovascular morbidity and mortality.
Follow-up with the patient postoperatively, when most perioperative cardiac events occur.
Table 16-1Surgery-specific Cardiac Risk |Favorite Table|Download (.pdf) Table 16-1 Surgery-specific Cardiac Risk
High-risk surgery (reported cardiac risk >5%)
Emergent major operation (particularly in the elderly)
Aortic and other major vascular
Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
Intermediate-risk surgery (reported risk <5%)
Head and neck
Intraperitoneal and intrathoracic
Low-risk surgery (reported risk <1%)
Table 16-2Active Cardiac Conditions |Favorite Table|Download (.pdf) Table 16-2 Active Cardiac Conditions
Unstable coronary syndrome—unstable or severe angina or recent MI
High-grade atrioventricular block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease
Table 16-3Clinical Risk Factors |Favorite Table|Download (.pdf) Table 16-3 Clinical Risk Factors
Ischemic heart disease
Prior or compensated CHF
Renal insufficiency (creatinine ≥2.0 mg/dL)
The preoperative evaluation begins with a thorough history with special emphasis on the need to identify clinical markers that increase perioperative risk as well as assess functional capacity:
Identify clinical markers that increase perioperative risk:
In the previous ACC/AHA guidelines from 2002, risk factors were separated into major, intermediate, and minor risk factors. The guidelines have recently been updated in 2007 with some ...