This chapter discusses the perioperative evaluation and management of cardiac disease in patients undergoing noncardiac surgery. In perioperative management, a careful history and physical examination directed at finding and grading cardiac disease is imperative. Evaluation of cardiac disease prior to surgery should involve consideration of whether the cardiac disease is active or stable, and of the urgency and risk of the procedure required. Active cardiac disease typically requires delay of surgery that is not time-sensitive (see accompanying Hurst’s Central Illustration). In patients with stable cardiac disease, risk-stratification methodologies, approaches to perioperative testing, and medical management are important components of perioperative evaluation. Perioperative risk stratification involves evaluation of the inherent risk of the noncardiac operation and of the risk attributed to patient-specific conditions. In the setting of stable cardiac disease, assessment of the patient’s symptoms, exercise status, and functional capacity should be used to determine whether further cardiac testing is required; further perioperative testing should be limited to circumstances that would change management independent of the surgery planned. After a thorough history, physical examination, and risk stratification, titration or addition of cardiac medications can be helpful in perioperative management of select patients with stable cardiac disease, though care should be taken to not begin or withdraw therapies abruptly in the perioperative period.
Hurst's Central Illustration: Strategies in patients with cardiac disease who are scheduled to undergo noncardiac surgery.
In patients with active cardiac disease, delay of nonemergent, nonurgent surgery is typically (but not always) required to manage the cardiac condition and reduce the chance of major cardiovascular adverse events.
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 (ACC)/American Heart Association (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. ACS, acute coronary syndrome; CAD, coronary artery disease; CPGs, clinical practice guidelines; GDMT, guideline-directed medical therapy; MACE, major ...