Over time, the perioperative evaluation of cardiac disease in patients undergoing noncardiac surgery has been the object 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, cardiac symptoms and signs, and whether they are acutely worsening are of paramount importance in guiding management decisions. As in the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC)/European Society of Anesthesiology (ESA) guidelines,1,2 we believe 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 Fig. 98–1.1
Summary algorithm for the cardiac evaluation and management of patients prior to noncardiac surgery from the 2014 ACC/AHA Clinical Practice Guidelines. Reproduced with permission from 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. Circulation. 2014 Dec 9;130(24):e278-e333.
TEMPORAL URGENCY AND RISK OF SURGERY
The time period in which surgery must take place is of critical importance in deciding how to evaluate patients preoperatively. This temporal urgency dictates the extent of clinical evaluation and potential changes in management prior to surgery. This is clearly reflected in the ACC/AHA clinical guideline writing group's classification scheme of emergent, urgent, time-sensitive, and elective for temporal necessity of surgery, which is summarized in Table 98–1.1
TABLE 98–1.Scheme for Classifying Surgical Urgency1 |Favorite Table|Download (.pdf) TABLE 98–1. Scheme for Classifying Surgical Urgency1
|Classification ||Definition |
|Emergent ||No time or only time for very limited clinical evaluation, life or limb threatened, surgery needed in < 6 hours |
|Urgent ||Time for a limited clinical evaluation, life or limb threatened, surgery needed in between 6 and 24 hours |
|Time sensitive ||A delay of > 1 to 6 weeks will significantly affect outcome (eg, oncologic surgery) |
|Elective ||Procedure may be delayed for up to one year |
Active cardiac disease typically requires delay of nonemergent, ...