A preoperative cardiac assessment involves several key components as outlined by the American College of Cardiology (ACC) and the American Heart Association (AHA).
Guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery:
Preoperative resting 12-lead ECG is reasonable for patients with known coronary heart disease or other significant structural heart disease, except for those undergoing low-risk surgery.
It may also be considered for asymptomatic patients, except for those undergoing low-risk surgery.
Routine ECG is not recommended for asymptomatic patients undergoing low-risk procedures
To evaluate LV function preoperatively in patients with dyspnea of unknown origin or in those with heart failure (HF) who have worsening dyspnea or other changes in clinical status.
Routine evaluation of LV function in clinically stable patients is not recommended.
For patients with elevated risk and excellent functional capacity, it is reasonable to proceed to surgery without further exercise testing.
For those with elevated risk and unknown functional capacity, exercise testing may be reasonable if it will change management.
Routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery
For patients at elevated risk with poor functional capacity, it is reasonable to undergo dobutamine stress echocardiography (DSE) or myocardial perfusion imaging (MPI) if it will change management.
A focused history and physical examination are essential to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease.
The use of risk calculators, such as the Revised Cardiac Risk Index, helps stratify patients into low-risk (<1%) and higher-risk (≥1%) categories for perioperative major adverse cardiovascular events (MACE).
Patients with poor functional capacity (<4 METs) may benefit from further cardiovascular testing if the results would alter perioperative management.
Noninvasive stress testing, such as exercise electrocardiography, myocardial perfusion scintigraphy, or stress echocardiography, is recommended for patients at intermediate or high risk based on clinical predictors and functional capacity.
Statins are associated with fewer postoperative cardiovascular complications and lower mortality and should be considered in patients with atherosclerotic cardiovascular disease undergoing vascular surgery.
The use of β-blockers should be carefully managed; high-dose β-blockers administered shortly before surgery are associated with increased risks of stroke and mortality and should not be routinely used.
The American Society of Anesthesiologists (ASA) emphasizes the importance of balancing the risks and costs of preoperative evaluations against their benefits, recommending that noninvasive and invasive cardiac testing be reserved for situations where the results will clearly impact patient management.
A preoperative cardiac assessment involves a detailed history and physical examination, risk stratification using validated tools, assessment of functional capacity, selective use of noninvasive testing, and appropriate pharmacologic management tailored to the patient’s specific risk profile.