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  • Cardiovascular complications in the perioperative period account for a substantial amount of morbidity and mortality.

  • The initial clinical evaluation of the patient should include a comprehensive history, physical examination, and assessment of current functional status, with the determination of overall clinical risk as assessed by an index, such as the revised cardiac risk index.

  • Patients at low risk, defined by the type of surgery and patient-specific risk, should not undergo routine noninvasive or invasive testing prior to surgery.

  • In moderate- to high-risk preoperative patients, radionuclide myocardial perfusion imaging (MPI) has been shown to effectively risk stratify patients for both short- and long-term cardiac outcomes.

  • Single-photon emission computed tomography (SPECT) MPI has been shown to be useful in several unique surgical cohorts, especially in renal transplant candidates.

A significant number of patients undergoing noncardiac surgical procedures have underlying coronary artery disease (CAD), and thus are at risk of major adverse cardiac events (MACE) in the perioperative period. Globally, of the 200 million patients who undergo noncardiac surgery each year, 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 an international cohort analysis.2,3 Recent data reveals a 16% incidence of perioperative myocardial injury, with an associated hazard ratio of 2.7 for 30-day mortality.4 Therefore, it is vital to perform a comprehensive cardiac risk assessment to identify patients who may benefit from risk reduction strategies prior to noncardiac surgery.

Cardiovascular perioperative risk assessment is vital for evaluating patients prior to surgery to optimize their cardiovascular safety and initiate lifestyle modifications that when coupled together provide short- and long-term benefits. The American College of Cardiology/American Heart Association (ACC/AHA) Task Force created guidelines for the perioperative risk assessment of cardiovascular disease for noncardiac surgery. Since the publication of the guidelines in 2007, data on perioperative cardiac risk factor modification and management have significantly changed, and these guidelines were subsequently updated in 2014.5

Goals of Preoperative Evaluation

As a physician/healthcare provider 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, in whom surgery may need to be altered or postponed.

  • Identify the risk of the proposed surgery (Table 21-1).

  • A thorough initial clinical evaluation of the patient, including a comprehensive history, physical examination, and assessment of current functional status.

  • Assess risk for major adverse perioperative cardiovascular events using a validated risk prediction tool, which is based upon patient data and procedure type.

  • If indicated, perform diagnostic testing (both noninvasive and invasive) to further determine the presence and severity of CAD and/or ischemia, and interventions to ...

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