2. Why it is necessary
• Approximately 500,000 to 900,000 patients per year undergoing non-
cardiac surgery suffer a perioperative cardiac death
• Impact of vascular disease and comorbidity on postoperative outcome
• Assess current medical status and cardiac risks posed by the planned
operation
• Recommend strategies that may influence short- and long-term outcomes
• In 1977 Goldman introduced the Cardiac Risk Index Score (CRIS) to guide
more quantitatively the assignment of cardiac risk in patients undergoing
noncardiac surgery.
3. Risk-stratification of surgery
Low Risk surgery (reported cardiac risk generally
<1%)
Endoscopic procedures,
Superficial procedure,
Cataract surgery,
Breast surgery,
Ambulatory surgery
Intermediate Risk surgery (reported cardiac risk generally 1%-
5%)
Intraperitoneal and intrathoracic
surgery,
Carotid endarterectomy Head and
neck surgery,
Orthopedic surgery,
Prostate surgery
High Risk surgery (reported cardiac risk often >5%) Aortic and other major vascular
surgery Peripheral vascular surgery
4. Life or limb is
threatened if not
in operating
room within
24 hours
Delay of >1-6
weeks
foranagement
further
evaluation
would negatively
affect outcome
Delay for up to
1 year
Life or limb is
threatened if not
in operating
room within
6 hours
Emergent Urgent
Time-
Sensitive
Elective
Definition of Timing of Surgery
ACCA/ AHA 2014
5. Patient scheduled for surgery with known or risk factors for CAD
(Step 1)
Emergency Yes Clinical risk stratification
and proceed to surgery
No
ACS†
(Step 2)
Yes
Treatment options should
be discussed in a multi-
disciplinary team.
No
Estimated perioperative risk of MACE
based on combined clinical/surgical risk
(Step 3)
Low risk (< 1%)
(Step 4)
No further
testing
(Class III:NB)
Proceed to
surgery
Elevated risk
(Step 5)
A stepwise approach
6. Elevated risk
(Step 5)
Moderate or greater
( 4 METs) functional
capacity
Excellent
(> 10 METs)
No further
testing
(Class IIa)
Moderate/Good
( 4–10 METs
No further
testing
(Class IIa)
Proceed to
surgery
Poor OR unknown
functional capacity
(< 4 METs):
Will further testing impact
decision making OR
perioperative care?
(Step 6)
No
Proceed to surgery according to GDMT OR alternate strategies
(noninvasive treatment,
palliation) (Step 7)
Yes
Pharmacologic
stress testing
(Class IIa)
If
abnormal
Coronary
revascularization
according to
existing CPGs
(Class I)
If
normal
7. Recommendations on routine pre-operative ECG
Supplemental Preoperative Evaluation
Recommendations COR LOE
Pre-operative ECG is recommended for patients who have risk factor(s)
and are scheduled for intermediate- or high-risk surgery. I C
Pre -operative ECG may be considered for patients who have risk factor(s)
and are scheduled for low-risk surgery. IIb C
Pre-operative ECG may be considered for patients who have no risk factors,
are above 65 years of age, and are scheduled for intermediate-risk surgery.
IIb
C
Routine pre-operative ECG is not recommended for patients who have no
risk factors and are scheduled for low-risk surgery.
III: No
Benefit
B
ESC guideline 2014
8. Timing of Elective Noncardiac Surgery in Patients With Previous
Revascularization
Recommendations COR LOE
Elective noncardiac surgery should be delayed 2 weeks(14
days) after balloon angioplasty… IIa B
…and 4 weeks (30 days) after BMS implantation
IIa B
Elective noncardiac surgery should optimally be delayed 12
months (365 day)s after DES implantation. This delay may be
reduced to 6 months for the new generation DES.
IIa
B
Perioperative Therapy
ESC guideline 2014
9. Antiplatelet Agents: Recommendations
COR LOE
It is recommended that aspirin be continued for 4 weeks after BMS implantation and for
12 months after DES implantation, unless the risk of life-threatening surgical bleeding on
aspirin is unacceptably high.
I C
Continuation of P2Y12 inhibitor treatment should be considered for 4 weeks after BMS
implantation and for 12 months after DES implantation,unless the risk of life-threatening
surgical bleeding on this agent is unacceptably high
II a C
In patients treated with P2Y12 inhibitors, who need to undergo surgery, postponing
surgery for at least 5 days after cessation of ticagrelor and clopidogrel—and
for 7 days in the case of prasugrel—if clinically feasible, should be considered unless the
patient is at high risk of an ischaemic event.
IIa C
ESC 2014
10. Perioperative Therapy
Perioperative Beta-Blocker Therapy
Recommendations COR LOE
Peri-operative continuation of betablockers is recommended in
patients currently receiving this medication.
I B
Pre-operative initiation of betablockers may be considered in patients
scheduled for high-risk surgery and who have 2 clinical risk factors IIb B
Pre-operative initiation of betablockers may be considered in patients
who have known IHD or myocardial ischaemia IIb B
When oral beta-blockade is initiated in patients who undergo non-
cardiac surgery, the use of atenolol or bisoprolol as a first choice may be
considered.
IIb B
Initiation of peri-operative high dose beta-blockers without
titration is not recommended
III
B
Pre-operative initiation of betablockers is not recommended in
patients scheduled for low-risk surgery. III
B
ESC guideline 2014
11. Perioperative Statin Therapy
Recommendations COR LOE
Statins should be continued in patients currently taking statins
and scheduled for noncardiac surgery. I C
Perioperative initiation of statin use is reasonable in patients
undergoing vascular surgery atleast 2 weeks before surgery. IIa B
Perioperative Therapy
ESC guideline 2014
Recommendations COR LOE
Continuation of ACEIs or ARBs, under close monitoring, should be
considered during non-cardiac surgery in stable patients with
heart failure and LV systolic dysfunction.
IIa C
Initiation of ACEIs or ARBs should be considered at least 1 week
before surgery in cardiac-stable patients with heart failure and LV
systolic dysfunction.
IIa C
Transient discontinuation of ACEIs or ARBs before non-cardiac
surgery in hypertensive patients should be considered.
IIa C
Angiotensin-Converting Enzyme Inhibitors/ ARB
12. Patients treated with oral anticoagulant
VKA or NOAC
• Patients treated with oral anticoagulant therapy using vitamin K
antagonists (VKAs) are subject to an increased risk of peri and post
procedural bleeding.
• Bridging anticoagulation is usually considered in patients at very high
thromboembolic risk (mechanical heart valves, recent [< 12 weeks]
embolic stroke, or venous thromboembolism
• If the international normalized ratio(INR) is ≤ 1.5, surgery can be
performed safely
• It is recommended that VKA treatment be stopped 3 – 5 days before
surgery (depending on the type of VKA), VKAs should be resumed on
1 or 2 day after surgery— depending on adequate haemostasis
13. Implanted cardiac rhythm devices
• Only bipolar cautery or a harmonic scalpel will be used
• In pacemaker-dependent patients, reprogramming to the DOO or
VOO setting can minimize oversensing and failure to pace
• In patients with ICDs, turning off tachy therapies is helpful to avoid
unnecessary patient shocks.
14. VALVULAR HEART DISEASE
• Echocardiography is critical for quantification of degree of stenosis or
regurgitation and determination of surgical risk.
• Symptomatic severe AS patients should undergo valve replacement prior to
surgery
• TAVR may be considered for patients with severe symptomatic disease for
whom open surgery is not an option
• Symptomatic mitral stenosis patients who are good candidates for balloon
valvulotomy or surgical commisurotomy should undergo treatment before
elective surgery.
• Left-sided regurgitant valve lesions are better tolerated than stenotic
lesions.
15. HEART FAILURE
• In the setting of active nonobstructive HF, it is optimal to delay
surgery for diuresis until euvolemia is achieved
• Special care must be taken in HOCM to avoid arterial dilation and
overdiuresis
• Natriuretic peptide measurement can help manage and predict
perioperative events
16. Hypertension
• The pharmacologic management of patients with hypertension
should be continued perioperatively
• BP should be maintained near preoperative levels to reduce the risk
for myocardial ischemia.
• A hypertensive crisis in the postoperative period—defined as
diastolic BP higher than 120 mm Hg and clinical evidence of
impending or actual end-organ damage—poses a definite risk for MI
and cerebrovascular accident (CVA, stroke)
17. Take home message
• Emergency surgery can be done in cardiac patients by
multidisciplinary team approach .
• B-blockers should be continued or started preoperatively in patients
with ischemic risk .
• In patients with coronary stents, aspirin is best to continued during
surgery and should be reinitiated as soon can be done safely if
stopped
• Surgery can be done in patients on anticoagulant if INR is less than
1.5 .
• Routine Echo is not recommended preoperatively however is
reasonable in patients with high risk surgery heart failure Or
unexplained dyspnoea.
