Cardiovascular disease is the leading cause of death worldwide. Of the 200 million patients who undergo noncardiac surgery each year the world over, approximately 10 million have a major perioperative cardiac complication within 30 days.1 Taken by itself, perioperative death constitutes the third leading cause of death in the United States and myocardial injury after noncardiac surgery is associated with a population attributable risk of 34% for death at 30 days in a recent international cohort analysis.2,3 With an aging and increasingly comorbid population, these numbers are expected to grow.
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. Myocardial perfusion imaging (MPI) can play an important role in this process. The American College of Cardiology/American Heart Association (ACC/AHA) task force committee created guidelines for the perioperative risk assessment of cardiovascular disease for noncardiac surgery. Since the last iteration of the guidelines in 2007, data on perioperative cardiac risk factor modification and management have significantly changed, and the guidelines were subsequently updated in 2014.4
Goals of Preoperative Evaluation
As a physician evaluates a patient prior to noncardiac surgery, several goals should be kept in mind:
Identify unstable patients who are at high risk for perioperative cardiac events.
Identify the risk of the proposed surgery (Table 16-1).
Assess risk for major adverse perioperative cardiovascular events using a validated risk prediction tool.
Determine the patient's functional capacity.
Perform diagnostic testing and interventions 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%)
The preoperative evaluation begins with a thorough history with special emphasis on the need to identify clinical markers of perioperative risk as well as to assess functional capacity.
In 2002, the ACC/AHA guidelines delineated major, intermediate, and minor risk factors for perioperative cardiac events. In 2007, the guidelines sought to identify patients at high risk for complications with surgery due to serious cardiac conditions such as unstable coronary syndromes, severe angina, recent myocardial infarction (MI), decompensated heart failure (HF), significant arrhythmias, and severe valvular disease that require urgent evaluation regardless of impending surgery. The most recent update ...