Cardiac patient posted for non cardiac surgery

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Cardiac Patient Posted for Non-Cardiac Surgery

The perioperative management of a cardiac patient undergoing non-cardiac surgery requires systematic stepwise assessment to minimize the risk of Major Adverse Cardiac Events (MACE). Myocardial infarction is the leading cause of both early and late postoperative deaths in this population.

Step 1 - Emergency vs. Elective Surgery

The very first decision:

Emergency surgery: Proceed directly to the operating room with optimization of monitoring and medical therapy intraoperatively. No time for extensive risk stratification.
Elective/urgent surgery: Proceed with full stepwise cardiac assessment below.

Step 2 - Identify Active Cardiac Conditions (Absolute Contraindications to Elective Surgery)

These must be evaluated and stabilized BEFORE proceeding:

Condition	Action
Acute Coronary Syndrome (NSTEMI/STEMI)	Treat per ACS guidelines first
Decompensated Heart Failure	Stabilize medically
Significant arrhythmias (high-grade AV block, symptomatic bradycardia, uncontrolled SVT)	Rate/rhythm control
Severe symptomatic valvular disease (especially severe aortic stenosis)	Evaluate for intervention
Unstable/severe angina	Optimize medically

Step 3 - Surgical Risk Stratification

Risk varies by the type of surgery:

Risk Category	Examples	MACE Risk
Low	Endoscopic, superficial, cataract, breast	<1%
Intermediate	Intraabdominal, intrathoracic, orthopedic, prostate, head/neck	1-5%
High	Vascular (aorta, peripheral), emergent major	>5%

Low-risk procedures: proceed without further cardiac testing.
Intermediate/high risk: continue to Steps 4 and 5.

Step 4 - Estimate MACE Risk Using Risk Indices

Revised Cardiac Risk Index (RCRI) - Lee Index (1999)

The most widely used and validated tool (endorsed by ACC/AHA, ESC, ESA).

Assigns 1 point each for:

High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular)
History of ischemic heart disease (prior MI, angina, positive stress test, pathological Q waves, nitrate use)
History of congestive heart failure (PND, pulmonary edema, S3 gallop, LV failure on exam)
History of cerebrovascular disease (TIA or stroke)
Insulin-dependent diabetes mellitus
Preoperative creatinine >2.0 mg/dL

RCRI Score and Predicted MACE Risk:

Score	Risk of Major Cardiac Events
0	~0.4%
1	~0.9%
2	~7%
≥3	~11%

Patients with RCRI ≥3 are at very high risk and may benefit from noninvasive stress testing or modification of management.

Other Risk Calculators

ACS NSQIP MICA Calculator (online at riskcalculator.facs.org): uses age, functional status, ASA class, creatinine, and surgery type
AUB-HAS2 Index: heart disease history, symptoms of heart disease (angina/dyspnea), age ≥75, anemia (Hb <12), vascular/emergency surgery

Step 5 - Functional Capacity Assessment

Expressed in Metabolic Equivalents (METs):

Functional Capacity	Examples	METs
Poor	Cannot climb one flight / walk on level	<4 METs
Moderate-Good	Climb stairs, walk on level at 4 mph, carry 15-20 lb objects, golf, doubles tennis	≥4 METs
Excellent	Strenuous sport, heavy physical labor	>10 METs

≥4 METs: Generally proceed to surgery without further noninvasive testing.
<4 METs or unknown: Consider pharmacological stress testing only if results would change management or perioperative care.

Step 6 - Preoperative Noninvasive Cardiac Testing

Indications are selective - NOT for all patients. Options include:

Dobutamine stress echocardiography (DSE)
Myocardial perfusion imaging with pharmacological stress (dipyridamole, adenosine, regadenoson) with Thallium-201 or Tc-99m
Exercise ECG stress test (if patient can exercise and resting ECG is interpretable)

Evidence for widespread preoperative noninvasive testing in all patients undergoing major surgery is lacking. Test only when results would alter clinical management.

Step 7 - Perioperative Medical Interventions (the algorithm)

Cardiac Risk Assessment Algorithm for Noncardiac Surgery

Beta-blockers

Continue if already on chronic beta-blocker therapy - do NOT withdraw perioperatively (withdrawal increases risk of ischemia/arrhythmia)
Do NOT initiate on the day of surgery
Consider initiating in intermediate- to high-risk patients (ideally days to weeks before surgery to assess tolerability), particularly those with ≥3 RCRI risk factors or intermediate/high-risk ischemia on stress testing
Titrate to heart rate 60-80 bpm

Statins

Continue if patient is already on a statin - associated with reduced perioperative cardiac complications
Initiate in patients undergoing vascular surgery (regardless of clinical risk)
Consider initiation in intermediate-/high-risk non-vascular procedures, though recent trial evidence (LOAD trial: atorvastatin 80 mg loading) showed no benefit in statin-naive patients

ACE Inhibitors / ARBs

Continue if used for heart failure or hypertension management
If held before surgery, restart as soon as clinically feasible postoperatively

Antiplatelet Therapy (Coronary Stents)

This is a critical consideration:

Stent Type	Minimum DAPT Duration Before Elective Surgery
Bare Metal Stent (BMS)	30 days
Drug-Eluting Stent (DES) - for stable IHD	6 months
DES - post-ACS	12 months

If P2Y12 inhibitor must be stopped: continue aspirin perioperatively, restart P2Y12 inhibitor ASAP postoperatively
Timing of stopping before surgery: Clopidogrel - 5 days; Prasugrel - 7 days; Ticagrelor - 3-5 days
Multidisciplinary decision-making (cardiologist + surgeon + anesthesiologist) is required

Alpha-2 Agonists (Clonidine)

NOT recommended - POISE-2 trial showed clonidine increased nonfatal cardiac arrest and clinically important hypotension

Calcium Channel Blockers

Insufficient evidence to recommend as prophylactic cardiac protection

SGLT-2 Inhibitors

Generally hold perioperatively (risk of euglycemic DKA)

Step 8 - Coronary Revascularization Before Non-Cardiac Surgery

The CARP trial established that prophylactic coronary revascularization (CABG or PCI) before non-cardiac surgery in high-risk patients with peripheral vascular disease and significant CAD did NOT reduce overall mortality or perioperative MI, and caused significant delays and increased limb morbidity. Therefore:

Routine preoperative revascularization is NOT recommended
Revascularization should be considered only if it would be indicated independently of the upcoming surgery (e.g., left main disease, severe 3-vessel disease with poor LV function, ACS)

Special Considerations

Patients with Heart Failure

Optimize volume status preoperatively
Avoid fluid overload intraoperatively
Monitor with invasive hemodynamic monitoring in severe cases
BNP/NT-proBNP can guide risk stratification

Patients with Valvular Heart Disease

Severe aortic stenosis: highest risk for perioperative cardiac events; consider valve replacement/TAVR before elective non-cardiac surgery if symptomatic
Mitral stenosis: control heart rate, avoid tachycardia
Regurgitant lesions: generally better tolerated

Patients with Arrhythmias / Pacemakers / ICD

Ensure pacemaker is functioning
For ICDs: discuss with electrophysiology team about intraoperative electromagnetic interference (electrocautery); consider reprogramming to asynchronous mode or deactivating tachycardia therapies during surgery
Patients with implanted cardiac devices should have device interrogated within 6-12 months of major surgery

Patients with Pulmonary Hypertension

High perioperative risk; requires specialist consultation
Avoid hypoxia, hypercarbia, acidosis, and pain (all increase pulmonary vascular resistance)

Preoperative Investigations in Cardiac Patients

Investigation	Indication
ECG	All cardiac patients preoperatively
Echocardiography	Known/suspected valvular disease, HF, new symptoms
Stress testing	Poor/unknown functional capacity + MACE risk >1% if results change management
BNP/NT-proBNP	Risk stratification in suspected/known HF
CBC	Expected major blood loss, symptoms of anemia, cardiac/pulmonary disease
Creatinine/electrolytes	Renal disease, diuretics, ACE inhibitor use
Coagulation	Anticoagulant use, liver disease
Glucose/HbA1c	Diabetes (cardiac risk factor)
CXR	Suspected pulmonary edema, known cardiac disease with new symptoms

Intraoperative Considerations

Monitoring: standard + invasive arterial line for high-risk patients; consider central venous access, TEE, pulmonary artery catheter in select cases
Maintain hemodynamic stability: avoid hypotension (systolic BP <100 mmHg), tachycardia (HR >80), and prolonged hypoxemia
Temperature regulation: hypothermia increases cardiac stress
Regional anesthesia: may be preferable in selected patients (reduces sympathetic response, avoids general anesthesia-related myocardial depression)
Continue beta-blockers intraoperatively

Postoperative Considerations

ECG in the immediate postoperative period and at 24-48 hours in high-risk patients
Troponin monitoring: rising troponin post-operatively (Myocardial Injury after Non-cardiac Surgery - MINS) is associated with worse outcomes
Early mobilization to reduce DVT/PE risk
Restart cardiac medications as soon as feasible
Adequate pain control (reduces sympathetic activation)

Sources:

Harrison's Principles of Internal Medicine 22E, Chapter 492 (Preoperative Evaluation and Perioperative Medicine)
Goldman-Cecil Medicine, Chapter 399 (Cardiovascular Risk in Noncardiac Surgery)
Sabiston Textbook of Surgery, Chapter 4 (Preoperative Assessment)
Schwartz's Principles of Surgery 11E, Chapter 23 (Peripheral Arterial Disease)
2022 ESC Guidelines on Cardiovascular Assessment and Management for Noncardiac Surgery

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