Overview

This lecture reviews the 2024 ACC/AHA guidelines for perioperative cardiovascular management in non-cardiac surgery, highlighting major updates, key risk assessment and management strategies, and new recommendations for biomarkers and medication use.

Risk & Functional Assessment

• Patients undergoing low-risk surgery do not need further cardiovascular testing.
• Perform risk assessment, functional capacity (using DASI score), and frailty assessment (>65 years or if frail).
• EKG is only recommended for symptomatic patients or those with risk factors.
• Use established tools (RCRI, NSQIP, Gupta) to classify patient and surgical risk.
• DASI score (functional capacity tool) receives a 2A recommendation; comprehensive over subjective assessment.

Cardiac Biomarkers

• BNP (B-type Natriuretic Peptide) recommended (Class 2A) preoperatively in elevated risk patients; troponin is Class 2B.
• Biomarkers are not advised for low-risk patients or low-risk surgeries.
• Elevated biomarkers help reclassify risk and guide perioperative management but do not change mortality.

Imaging & Stress Testing

• Routine preoperative stress testing and cardiac imaging (Echo, CT, MRI) are not recommended unless severe CAD is suspected.
• Stress testing and CT have only 2B recommendations and provide limited additional value over risk scores.
• Coronary angiography/revascularization is only indicated for suspected left main/multivessel disease affecting EF.

Medical Therapy Recommendations

• Continue antihypertensive, diabetic, and statin therapy; optimize risk factor control.
• SGLT2 inhibitors should be held 3-4 days pre-op; continue metformin and most other GDMT.
• For heart failure, continue GDMT except for SGLT2 inhibitors.

Antiplatelet & Anticoagulation Management

• Delay surgery after PCI: 14 days for balloon angioplasty, 30 days for bare-metal stent, 12 months for DES unless urgent.
• Continue aspirin for prior PCI; only start aspirin if indicated (e.g., prior ACS).
• Routine bridging is not recommended except for high-thrombotic-risk cases (e.g., mechanical valves).

Perioperative Cardiac Complications

• Recognize MINS (Myocardial Injury after Non-Cardiac Surgery); monitor troponin at 24 and 48 hours post-op if indicated.
• Treat MINS with risk factor modification and GDMT, not routine cath or revascularization.
• Post-op atrial fibrillation requires full evaluation and anticoagulation due to elevated stroke risk.

Special Populations

• For kidney and liver transplant candidates, avoid routine stress testing or revascularization unless high-risk anatomy or large ischemia is suspected.

Key Terms & Definitions

• RCRI (Revised Cardiac Risk Index) — Tool to estimate perioperative cardiac risk.
• DASI (Duke Activity Status Index) — Questionnaire assessing functional capacity.
• Frailty assessment — Evaluation to predict surgical risk in older or frail patients.
• BNP/Troponin — Cardiac biomarkers for preoperative risk stratification.
• GDMT (Guideline-Directed Medical Therapy) — Standard medical therapies for cardiovascular disease.
• MINS — Myocardial injury after non-cardiac surgery, detected by elevated troponin.

Action Items / Next Steps

• Use DASI and frailty assessments for all appropriate pre-op evaluations.
• Order BNP for elevated risk patients and consider troponin when indicated.
• Avoid routine cardiac imaging or stress testing except for high-risk cases.
• Review and optimize all cardiac and metabolic therapies before surgery.
• Monitor post-op troponin and manage MINS or new atrial fibrillation as per guidelines.
• Read the 2024 ACC/AHA guidelines for detailed recommendations.

Certainly! Here is a detailed, step-by-step elaboration of the Stepwise Approach to Risk Assessment and Management in perioperative cardiovascular care, integrating the latest 2024 ACC/AHA guidelines:

Stepwise Approach to Perioperative Cardiovascular Risk Assessment and Management

Step 1: Initial Clinical Evaluation

Purpose:

To gather comprehensive patient information to identify cardiovascular risk factors and symptoms that may influence perioperative risk.

Actions:

• History Taking:

  • Document known cardiovascular diseases: ischemic heart disease, heart failure, arrhythmias, cerebrovascular disease.
  • Identify risk factors: diabetes, hypertension, chronic kidney disease, smoking, hyperlipidemia.
  • Assess for symptoms suggestive of active cardiac disease: chest pain, dyspnea, palpitations, syncope.
  • Review prior cardiac interventions: PCI, CABG, valve surgery.
  • Medication history: adherence to GDMT, anticoagulants, antiplatelets.

• Physical Examination:

  • Vital signs: blood pressure, heart rate, oxygen saturation.
  • Cardiac exam: murmurs, gallops, signs of heart failure.
  • Signs of frailty: muscle wasting, gait instability.

• Initial Labs and Tests:

  • Baseline labs as per institutional protocol.
  • EKG only if symptoms or risk factors present.

Clinical Pearls:

• Avoid routine EKG in asymptomatic low-risk patients.
• Document baseline functional status and frailty indicators.

Step 2: Determine Surgical Risk

Purpose:

To classify the planned surgery’s inherent cardiovascular risk, which influences the need for further evaluation.

Actions:

• Classify surgery as:

  • Low-risk: Procedures with <1% risk of major adverse cardiac events (MACE), e.g., cataract surgery, breast surgery, minor outpatient procedures.
  • Elevated/high-risk: Procedures with ≥1% risk of MACE, e.g., vascular surgery, major abdominal/thoracic surgery, solid organ transplant.

• Consider potential for intraoperative conversion from minimally invasive to open surgery, which may increase risk.

Clinical Pearls:

• Surgical risk classification guides the intensity of preoperative cardiac evaluation.
• Low-risk surgeries generally do not require further cardiac testing regardless of patient risk.

Step 3: Calculate Patient Risk Using Validated Tools

Purpose:

To objectively quantify the patient’s baseline cardiovascular risk.

Actions:

• Use one or more of the following tools:

  • Revised Cardiac Risk Index (RCRI):
    • Variables: high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, renal dysfunction.
    • Score ≥1 indicates elevated risk.
  • NSQIP Risk Calculator:
    • More comprehensive; includes demographics, comorbidities, and surgical factors.
  • Gupta Score:
    • Shorter, anesthesia-focused.

• Classify patient risk as:

  • Low risk (<1%)
  • High risk (≥1%)

Clinical Pearls:

• Use the tool most familiar and practical in your clinical setting.
• Remember the binary risk classification simplifies decision-making.

Step 4: Assess Functional Capacity

Purpose:

To evaluate the patient’s ability to perform physical activities, which correlates with cardiovascular reserve and perioperative risk.

Actions:

• Administer the Duke Activity Status Index (DASI) questionnaire:
  • Assesses ability to perform activities such as walking, climbing stairs, housework.
  • Provides a score correlating with metabolic equivalents (METs).
• Interpret functional capacity:
  • Good functional capacity: >4 METs (e.g., able to climb stairs, walk 4 blocks).
  • Poor functional capacity: <4 METs.

Clinical Pearls:

• DASI is preferred over subjective single-question assessments.
• Poor functional capacity may prompt further testing or optimization.

Step 5: Assess Frailty

Purpose:

To identify patients with decreased physiological reserve who are at higher risk of postoperative complications.

Actions:

• Use the Clinical Frailty Scale (CFS):
  • Nine-point scale ranging from very fit (1) to terminally ill (9).
  • Scores ≥5 indicate frailty.
• Consider frailty assessment for:
  • All patients >65 years.
  • Younger patients who appear frail clinically.

Clinical Pearls:

• Frailty assessment can guide prehabilitation or reconsideration of surgery.
• Frail patients may benefit from multidisciplinary care and optimization.

Step 6: Decide on Further Testing Based on Combined Risk

Purpose:

To determine if additional cardiac testing or interventions are warranted.

Decision Algorithm:

Clinical Pearls:

• Avoid routine stress testing or imaging in low-risk patients/surgeries.
• Use biomarkers (BNP, troponin) in elevated-risk patients to refine risk.
• Imaging (stress test, CCTA) reserved for suspected severe CAD or if results will change management.

Step 7: EKG Use

Purpose:

To detect active cardiac abnormalities that may influence perioperative management.

Actions:

• Perform EKG only if:
  • Patient has symptoms suggestive of cardiac disease.
  • Patient has significant cardiovascular risk factors.
• Avoid routine EKG in asymptomatic low-risk patients.

Clinical Pearls:

• Overuse of EKG leads to unnecessary downstream testing.
• Targeted use improves diagnostic yield and resource utilization.

Step 8: Integrate Findings and Plan Management

Purpose:

To synthesize clinical, functional, frailty, biomarker, and imaging data into a perioperative plan.

Actions:

• For low-risk patients and surgeries with good functional capacity and no frailty, proceed with surgery without further testing.
• For elevated-risk patients:
  • Optimize GDMT (antihypertensives, statins, diabetes control).
  • Consider delaying surgery if uncontrolled risk factors.
  • Use biomarkers to guide monitoring and postoperative care.
  • Use imaging selectively to identify high-risk anatomy.
• Engage multidisciplinary team (cardiology, anesthesia, surgery) for complex cases.

Clinical Pearls:

• The goal is to balance risk reduction with avoiding unnecessary delays.
• Patient-centered decision-making is essential.

Step 9: Documentation and Communication

Purpose:

To ensure clear communication among care teams and with the patient.

Actions:

• Document risk assessment findings, functional and frailty scores.
• Communicate rationale for testing or no testing.
• Discuss perioperative risks and management plan with patient and surgical team.

Clinical Pearls:

• Clear documentation supports coordinated care.
• Educating patients about their risk improves shared decision-making.

Summary Table: Stepwise Risk Assessment and Management

If you want, I can provide clinical case examples illustrating this stepwise approach or help you create a flowchart for easy reference. Would you like that?