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Preop Assessment

Preoperative The following preoperative interventions are definitely beneficial:

Smoking cessation for eight weeksInhaledipratropiumortiotropiumfor all patients with clinically significant COPDInhaled beta-agonists for patients with COPD or asthma who have wheezes or

dyspnea

Preoperative glucocorticoids for patients with COPD or asthma who are not optimizedand whose airway obstruction has not been maximally reduced

Delay elective surgery if respiratory infection presentAntibiotics for patients with infected sputumPreoperative inspiratory muscle training

Intraoperative The following intraoperative interventions are definitely beneficial:

Choose alternative procedure lasting less than three to four hours when possibleMinimize duration of anesthesiaSurgery other than upper abdominal or thoracic when possibleRegional anesthesia (nerve block) in very high-risk patientsAvoid use ofpancuroniumas a muscle relaxant in high-risk patients

Choosing laparoscopic rather than open abdominal surgery when possible may be beneficial.

Epidural or spinal anesthesia may confer lower risk than general anesthesia, though this

remains an area of debate. Perioperative pulmonary artery catheterization is not beneficial.

Postoperative The following postoperative interventions are definitely beneficial:

Deep breathing exercises or incentive spirometry in high risk patientsEpidural analgesia in place of parenteral opioids

Continuous positive airway pressure (CPAP), intercostal nerve blocks, and selective use of

nasogastric tubes (for symptoms only) after abdominal surgery are probably beneficial

postoperative interventions.

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SUMMARY AND RECOMMENDATIONS The process of estimating and reducing the risk

of perioperative cardiac events (eg, cardiac death and nonfatal MI), includes the following

four components:

Defining the urgency of surgery, which may supersede risk stratification.Initial risk assessment.Refinement of initial risk assessment with noninvasive testing in selected patients.Consideration of therapies that may reduce risk in high-risk patients (eg,

revascularization, beta blockers, and statins).

Initial risk assessment The initial risk assessment consists of three steps.

Does the patient have a high risk condition that is considered a major predictor ofrisk in the 2007 ACC/AHA guidelines (eg, unstable angina or recent MI [within 7 to

30 days], decompensated heart failure, severe heart valve disease) [81]? Such

patients require intensive management and often a delay in or cancellation of

surgery.

What is the surgery-specific risk of the planned operation?What is the patient-specific risk? This can be estimated using the revised cardiac risk

index (RCRI) (table 2). The indications for noninvasive stress testing in

asymptomatic patients are estimated high risk (3 RCRI criteria) or intermediate

risk (1 to 2 RCRI criteria) plus poor or indeterminate functional status, a history

consistent with coronary disease, or high-risk surgery.

Patients requiring emergency surgery typically do not undergo stress testing. In addition,

the patient's long-term cardiac prognosis independent of surgery should be taken into

account when deciding to proceed with surgery or to perform preoperative coronary

revascularization.

In addition, patients should be assessed at the time of the preoperative evaluation for the

need for long term beta blocker use. In these patients, we recommend the initiation of beta

blockers days, and preferably weeks before surgery. For those patients who cannot receive

them in this time frame, we advise against their initiation hours before surgery.

Angiography and revascularization

Cardiac catheterization and angiography should be performed in patients with highrisk features on noninvasive testing (eg, reversible large anterior wall defect,

multiple reversible defects, ischemia occurring at a low heart rate, extensive

stress-induced wall motion abnormalities, transient ischemic dilatation).

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Among patients in whom preoperative coronary angiography is performed, werecommend revascularization only in patients who have high-risk features that

fulfill current criteria applicable to all patients with coronary disease. In patients

without such indications, the CARP trial and DECREASE-V Pilot Study found no

improvement in outcomes with revascularization compared to medical therapy.

We recommend that elective noncardiac surgery be postponed until after myocardialrevascularization has been performed.

Because of the risk of stent thrombosis, which can be a catastrophic complication,we recommend NOT performing PCI with stenting if surgery cannot be reasonably

delayed beyond the minimum recommended duration of combined antiplatelet

therapy (one month for bare metal stents and twelve months for drug-eluting

stents according to labeling instructions). Such patients can be treated with

angioplasty alone, waiting at least one week before performing noncardiac surgery

to permit healing of vessel injury at the balloon treatment site.

Beta blockers Beta blockers are recommended for many patients with known coronary

artery disease or myocardial ischemia by stress testing, unless there are contraindications.

In patients scheduled for vascular surgery who have stable CAD, documentedmyocardial ischemia, or high cardiac risk (RCRI 3) (table 2), we suggest

initiating perioperative beta blockade (Grade 2C). If beta blocker therapy is

prescribed, the drug should be started at least 30 days before surgery and the

dose should be titrated. In addition the patient should have close pre- and

perioperative monitoring of heart rate and blood pressure to assure that the beta

blocker is tolerated.

Although there is a reduction in the rate of perioperative myocardial infarction, and possible

a reduction in mortality in these patients, there is a concern about in increased rate of

stroke. These issues should be discussed with the patient. Physicians and patients may

reasonably choose to defer adding beta blocker therapy in such patients if they feel the risks

outweigh the benefits. Examples include patients scheduled for lower risk vascular surgery

(carotid endarterectomy) or those with a history of cerebrovascular accident for whom

perioperative hypotension might be particularly concerning.

We suggest continuing perioperative beta blockade in patients already being treatedwith beta blockers (Grade 2B).

In patients at high cardiac risk (RCRI 3) scheduled for intermediate risk surgery,there is insufficient evidence upon which a recommendation can be made. The

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benefits and risks of the preoperative initiation of beta blockers in this setting

should be discussed in detail with the patient.

Statins

Among patients undergoing elective major vascular surgery, we recommendcontinuing statin therapy in patients already being treated and, in previously

untreated patients, initiating statin therapy as soon as possible before elective

vascular surgery (Grade 1A). (See'Statins'above.)

For patients on statin therapy undergoing urgent or emergent major vascularsurgery, we recommend continuing such therapy (Grade 1B).

For patients not on statin therapy undergoing urgent or emergent major vascularsurgery, we suggest initiating therapy before surgery, if possible (Grade 2C).

Over the long-term, we recommend that statin therapy be titrated to recommendedgoals (Grade 1A).

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