BOTTOM LINE ✔ If emergent non-cardiac surgery needed, operate with post-op risk stratification and management. ✔ The National Surgical Quality Improvement Program (NSQIP) Risk Calculator can identify patients at increased risk for perioperative cardiac complications. ✔ Delay elective surgery for 4-6 weeks after angioplasty without stenting or bare metal stent placement and 12 months after drug eluting stent placement, if antiplatelet drugs.

Resident Editor: Mia Williams, MD

Faculty Editor:  Hugo Cheng, MD

Step 1. Active cardiac conditions?

Active cardiac conditions
Unstable Angina MI within 1 month Decompensated CHF Severe valvular disease: ● Symptomatic MS ● Severe AS	Serious arrhythmia: ● High grade AV block ● SVT with HR >100 ● Symptomatic bradycardia ●Ventricular arrhythmias

If YES, Delay surgery until evaluation and treatment per ACC/AHA guidelines

If NO, Continue to Step 3

Step 2. Low risk surgery?

Low Risk Surgery (<1% risk of perioperative death or MI)

If YES, Proceed with surgery; noninvasive tests not useful for low risk surgery.

If NO, Continue to Step 3

Examples of Surgeries by Risk

Low risk (<1% risk of peri-operative death or MI)	Intermediate Risk (1-5% risk of peri-operative death or MI)	High Risk (>5% risk of peri-operative death or MI)
Cataract removal Endoscopy Superficial procedure Breast surgery Ambulatory surgery	Urologic Orthopedic Intraperitoneal Intrathoracic Head and Neck Carotid Endarterectomy	Emergent major surgery Peripheral vascular Aortic surgery Prolonged procedures with large fluid shifts/blood loss

Step 3. What is the patient’s risk for cardiac complications?

Evaluate level of using the Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP) Risk Calculator

RCRI Clinical Risk Factors:

1. Ischemic heart disease
2. Heart Failure
3. Cerebrovascular disease
4. Renal Insufficiency (Cr>2.0)
5. Diabetes Mellitus
6. Major Surgery: intrathoracic, intraperitoneal, or suprainguinal vascular

Risk of perioperative death or MI:

0 predictors = 0.4%; 1 predictor = 1%; 2  predictors = 2.4 %;  ≥3 predictors = 5.4%

NSQIP Risk Calculator: https://qxmd.com/calculate/calculator_245/gupta-perioperative-cardiac-risk

Step 4. Functional capacity ≥4 METs without symptoms?

Activities ≥ 4 METs include:

• Climbing a flight of stairs
• Walking 1-2 blocks on level ground
• Performing light house work without symptoms

If YES, Proceed with surgery

If NO/UNKNOWN, Continue to Step 5.

Step 5. Will stress testing change management?

Perform pharmacologic stress test if result will change management (e.g., modify, delay, or cancel surgery, perform invasive cardiac intervention, modify medical management)

If stress testing negative, Proceed with surgery

If stress testing positive, Manage cardiac issues per AHA/ACA guidelines before proceeding with surgery.

Perioperative cardiac medications:

• Continue β-blockade prior to surgery if already receiving β-blockade.
• Consider initiating β-blockade in high-risk patients (>3 RCRI predictors or ischemia found on preoperative stress test)
• Do not start beta-blockers on the day of surgery.
• Initiate or continue statin therapy 1 month prior to surgery

Perioperative management of coronary stents:

• Coronary revascularization for stable coronary artery disease has not been shown to prevent cardiac complications after non-cardiac surgery
• Delay elective surgery for 1 month after bare metal stent implantation and 6 months after drug-eluting stent implantation (if this delay will cause significant harm, a delay of 3 months can be considered)
• Endocarditis prophylaxis is only recommended for patients undergoing dental, repiratory tract, and infected soft tissue procedures if they have prosthetic valves, history of infectious endocarditis, unrepaired cyanotic defects, or valvulopathy following heart transplant. Recommended antibiotic regimen: Amoxicillin 2 g PO x1 30-60 minutes prior to procedure. If PCN allergic, can use Azithromycin 500 mg or Clindamcyin 600 mg x1 30-60 minutes prior to procedure.

 

References

Gupta PK1, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, Esterbrooks DJ, Hunter CB, Pipinos II, Johanning JM, Lynch TG, Forse RA, Mohiuddin SM, Mooss AN. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011 Jul 26;124(4):381-7.

Fleisher, L.A., Fleischmann, K.E., Auerbach, A.D., et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Journal of the American College of Cardiology. 2014.

Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease, Journal of the American College of Cardiology  (2016), doi: 10.1016/j.jacc.2016.03.513

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007; 116(15):1736-54.