CHAPTER 98: PERIOPERATIVE EVALUATION FOR NONCARDIAC SURGERY

Summary

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.