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The prevalence of cardiovascular disease and the death rate associated with it rise sharply after age 45, an age when the incidence of noncardiac surgeries is also increasing. Thus, about one-third of the surgical procedures done annually in the United States are performed in patients with cardiovascular diseases. Cardiac deaths and nonfatal myocardial infarction (MI) occur in about 0.2% of all cases of general anesthesia and surgery (about 500,000 events annually). Cardiac deaths account for approximately 40% of all perioperative mortality, the same proportion as sepsis, although in many cases, the cause of death is multisystem organ failure. These figures underestimate the total effect of cardiovascular diseases because another 500,000 persons a year suffer nonfatal MI, unstable angina, or congestive heart failure (CHF) perioperatively, prolonging both their time in the intensive care unit and the total hospital stay.
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Although there is great potential to reduce perioperative cardiovascular risk, it is also impractical, unnecessary, and potentially harmful to perform cardiovascular testing in all patients prior to noncardiac surgery. Therefore, it is important to estimate perioperative risk, decide whether cardiac testing is appropriate, and provide prophylactic treatment to reduce risk when appropriate.
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PREOPERATIVE RISK ASSESSMENT
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An individual patient’s preoperative risk profile depends on three main factors: the patient’s age, current medical and functional status, and the type of surgery.
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Table 10–1 lists cardiac risk based on type of noncardiac surgery. In the evaluation of perioperative patients, understanding the nature of the surgery is of prime importance. Is this an emergency surgery? If yes, the clinician should advise to proceed with the surgery and evaluate the patient’s cardiac risk postoperatively. On the other hand, if the patient is young, without systemic disease, and undergoing a minor surgery or procedure, the clinician should advise to proceed with surgery without further cardiac workup. Also, in high-risk patients such as those with unstable angina, acute heart failure, symptomatic ventricular tachycardia, or recent MI, surgery should be postponed if possible until their risk is lowered. However, most patients are not so straightforward. In these patients, various algorithms can help identify perioperative risk and the need for further cardiac testing.
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