- Fleisher L.A.
- Fleischmann K.E.
- Auerbach A.D.
- et al.
- Kristensen S.D.
- Knuuti J.
- Saraste A.
- et al.
Preoperative Cardiac Risk Assessment
Which Patients Should Undergo Cardiac Risk Assessment Before Noncardiac Surgery?
- 1.In patients who require emergency surgery, we recommend against delaying surgery for a preoperative cardiac risk assessment.
- 2.In patients who require urgent or semiurgent surgery, we recommend undertaking preoperative cardiac risk assessment only if the patients' history or physical examination suggests there is a potential undiagnosed severe obstructive intracardiac abnormality, severe pulmonary hypertension, or an unstable cardiovascular condition.
- 3.In patients who undergo elective noncardiac surgery who are 45 years of age or older or 18-44 years of age with known significant cardiovascular disease, we recommend they undergo preoperative cardiac risk assessment.
- 4.We recommend communicating to patients their perioperative cardiac risk.
- 5.We recommend explicit communication of perioperative cardiac risk on the basis of the expected event rate among 100 patients or the range of risk consistent with the 95% confidence interval (CI) of the risk estimate (Strong Recommendation; Moderate-Quality Evidence).
Methods of preoperative cardiac risk assessment
Clinical risk indices
|History of ischemic heart disease|
|History of congestive heart failure|
|History of cerebrovascular disease|
|Use of insulin therapy for diabetes||1|
|Preoperative serum creatinine > 177 μmol/L (> 2.0 mg/dL)||1|
|Total RCRI points||Risk estimate, %||95% CI for the risk estimate|
- 6.When evaluating cardiac risk, we suggest clinicians use the RCRI over the other available clinical risk prediction scores (Conditional Recommendation; Low-Quality Evidence).
Self-reported functional capacity
- Fleisher L.A.
- Fleischmann K.E.
- Auerbach A.D.
- et al.
- Rodseth R.N.
- Biccard B.M.
- Le Manach Y.
- et al.
- Rodseth R.N.
- Biccard B.M.
- Le Manach Y.
- et al.
- Karthikeyan G.
- Moncur R.A.
- Levine O.
- et al.
- 7.We recommend measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have an RCRI score ≥ 1 (Strong Recommendation; Moderate-Quality Evidence).
- Values and preferences. Cost and accessibility were considered important determinants of biomarker selection. Considering cost, we restricted testing to patient groups that had a baseline clinical risk estimate > 5%. Data from the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study showed that patients 65 years of age or older or 45-64 years of age with known cardiovascular disease have a baseline risk > 5% for cardiovascular death or nonfatal myocardial infarction at 30 days after surgery, whereas patients without these characteristics have a ≤ 2.0% 30-day event rate.2Compared with cardiac imaging and noninvasive cardiac stress testing, NT-proBNP/BNP biomarkers are inexpensive and avoid the need for return visits.
|Test result||Risk estimate, %||95% CI for the risk estimate|
|NT-proBNP < 300 ng/L or BNP < 92 mg/L||4.9||3.9%-6.1%|
|NT-proBNP value ≥ 300 ng/L or BNP ≥ 92 mg/L||21.8||19.0%-24.8%|
- 8.We recommend against performing preoperative resting echocardiography to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
Coronary computed tomographic angiography
- 9.We recommend against performing preoperative CCTA to enhance perioperative cardiac risk estimation (Strong Recommendation; Moderate-Quality Evidence).
Exercise stress testing and cardiopulmonary exercise testing
- 10.We recommend against performing preoperative exercise stress testing to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
- 11.We recommend against performing preoperative CPET to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
Pharmacological stress echocardiography and radionuclide imaging
- 12.We recommend against performing preoperative pharmacological stress echocardiography to enhance perioperative cardiac risk estimation (Strong Recommendation; Low-Quality Evidence).
- 13.We recommend against performing preoperative pharmacological stress radionuclide imaging to enhance perioperative cardiac risk estimation (Strong Recommendation; Moderate-Quality Evidence).
- Values and preferences. The panel believed that the cost and potential delays associated with these stress tests should be taken into account because of the absence of evidence of an overall absolute net improvement in risk reclassification.
Perioperative Cardiac Risk Modification
|Management of medications taken chronically and smoking before noncardiac surgery|
|ASA||Withhold at least 3 days before surgery|
†and restart ASA when the risk of bleeding related to surgery has passed (ie, 8-10 days after major noncardiac surgery)
|β-Blocker||Continue the β-blocker during the perioperative period; however, if a patient's systolic blood pressure is low before surgery, physicians should consider decreasing or holding the dose of the β-blocker before surgery|
|ACEI/ARB||Withhold ACEI/ARB 24 hours before noncardiac surgery and restart ACEI/ARB on day 2 after surgery, if the patient is hemodynamically stable|
|Statin||Continue the statin during the perioperative period|
|Smoking||Discuss and facilitate smoking cessation (eg, nicotine replacement therapy), ideally starting ≥ 4 weeks before surgery|
|Initiation of new medications and coronary revascularization before noncardiac surgery|
|ASA||Do not initiate ASA for the prevention of perioperative cardiac events|
|β-Blocker||Do not initiate a β-blocker within 24 hours before noncardiac surgery|
|α2-Agonist||Do not initiate an α2-agonist for the prevention of perioperative cardiovascular events|
|Calcium channel blocker||Do not initiate a calcium channel blocker for the prevention of perioperative cardiovascular events|
|Coronary revascularization||Do not undertake preoperative prophylactic coronary revascularization for patients with stable coronary artery disease|
Perioperative use of acetylsalicylic acid
- 14.We recommend against initiation of ASA for the prevention of perioperative cardiac events (Strong Recommendation; High-Quality Evidence).
- 15.We recommend against the continuation of ASA to prevent perioperative cardiac events, except in patients with a recent coronary artery stent and patients who undergo carotid endarterectomy (Strong Recommendation; High-Quality Evidence).
- Devereaux P.J.
β-Blockade initiation before noncardiac surgery
- Wijeysundera D.N.
- Duncan D.
- Nkonde-Price C.
- et al.
- 16.We recommend against β-blocker initiation within 24 hours before noncardiac surgery (Strong Recommendation; High-Quality Evidence).
β-Blocker continuation during the perioperative period
- 17.Among patients taking a β-blocker chronically, we suggest to continue the β-blocker during the perioperative period (Conditional Recommendation; Low-Quality Evidence).
α2-Agonist initiation before noncardiac surgery
- 18.We recommend against preoperative initiation of an α2-agonist for the prevention of perioperative cardiovascular events (Strong Recommendation; High-Quality Evidence).
Calcium channel blocker initiation before noncardiac surgery
- 19.We suggest against the initiation of calcium channel blockers for the prevention of perioperative cardiovascular events (Conditional Recommendation; Low-Quality Evidence).
Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker continuation in the perioperative period
- 20.We recommend withholding ACEI/ARB starting 24 hours before noncardiac surgery in patients treated chronically with an ACEI/ARB (Strong Recommendation; Low-Quality Evidence).
- Values and preferences. Weight was accorded to the absence of demonstrated benefit and the substantial increase in the risk of intraoperative hypotension associated with perioperative continuation of ACEI/ARB therapy.
Statin initiation before noncardiac surgery
Statin continuation in the noncardiac surgery setting
- 21.We recommend continuing statin therapy perioperatively in patients who are receiving chronic statin therapy (Strong Recommendation; Moderate-Quality Evidence).
Coronary artery revascularization before noncardiac surgery
- 22.For patients with stable coronary artery disease who undergo noncardiac surgery, we recommend against preoperative prophylactic coronary revascularization (Strong Recommendation; Low-Quality Evidence).
- Values and preferences. In the absence of clearly demonstrated benefit, the potential for surgical delays, increase in costs, and risk of bleeding with dual antiplatelet therapy supported a strong recommendation against prophylactic preoperative coronary revascularization.
Smoking cessation before noncardiac surgery
- 23.We recommend discussing and facilitating smoking cessation before noncardiac surgery (Strong Recommendation; Low-Quality Evidence).
- Values and preferences. Because even brief counselling on smoking cessation during preoperative evaluation might positively affect smoking cessation, the panel members believe it is important to take advantage of this opportunity to optimize long-term cardiac risk.
Monitoring for Perioperative Cardiac Events
- 24.We recommend obtaining daily troponin measurements for 48-72 hours after noncardiac surgery in patients with a baseline risk > 5% for cardiovascular death or nonfatal myocardial infarction at 30 days after surgery (ie, patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older) (Strong Recommendation; Moderate-Quality Evidence).
- 25.We suggest performing a postoperative ECG in the postanesthetic care unit in patients with an elevated NT-proBNP/BNP measurement before surgery or, if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older (Conditional Recommendation; Low-Quality Evidence).
Pulmonary artery catheter monitoring
- 26.We recommend against the use of pulmonary artery catheters in patients who undergo noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).
Postoperative shared-care management
- 27.We suggest shared-care management of patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥ 1, age 45-64 years with significant cardiovascular disease, or age 65 years or older (Conditional Recommendation; Low-Quality Evidence).
Management of Postoperative Events
ASA and statin in patients who suffer MINS
- 28.We recommend the initiation of long-term ASA in patients who suffer a myocardial injury or myocardial infarction after noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).
- 29.We recommend the initiation of long-term statin therapy in patients who suffer myocardial injury or myocardial infarction after noncardiac surgery (Strong Recommendation; Moderate-Quality Evidence).
- Values and preferences. Although these data are limited to risk-adjusted observational data, the panel believed that the current available data support the use of ASA and a statin in patients who suffer a myocardial injury or myocardial infarction after noncardiac surgery. Panel members also considered the overwhelming evidence of the beneficial effects of ASA and statin after cardiac events in the nonsurgical setting.
Conclusions and Future Research
- Supplementary Material
|Primary Panel Members|
|Co-chairs: Drs P.J. Devereaux, Joel Parlow|
|Members: Drs Amal Bessissow, Gregory Bryson, Emmanuelle Duceppe, Michelle Graham, Kristin Lyons, Paul MacDonald, Michael McMullen Daniel I. Sessler, Sadeesh Srinathan, Kim Styles, Vikas Tandon|
|Secondary Panel Members|
|Drs Rebecca Auer, Mohit Bhandari, Davy Cheng, Peter Choi, Benjamin Chow, Gilles Dagenais, Josée Fafard, Gordon Guyatt, John Harlock, David Hornstein, Michael Jacka, Andrea Kurz, Luc Lanthier, Yannick LeManach, Finlay McAlister, Edward McFalls, Michael McGillion, Marko Mrkobrada, Ameen Patel, Tej Sheth, Maria Tiboni, Duminda Wijeysundera|
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The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.