Thorough Risk Assessment Essential Prior to Noncardiac Surgery

Comprehensive preoperative assessment of cardiovascular risk with history and physical examination is essential prior to noncardiac surgery, according to a review published in the July 21 issue of the Journal of the American Medical Association.

Nathaniel R. Smilowitz, MD, and Jeffrey S. Berger, MD, both from the New York University School of Medicine in New York City, conducted a literature review to summarize evidence regarding cardiovascular risk assessment prior to noncardiac surgery.

The researchers found support for a thorough history and physical examination to identify signs of ischemic heart disease, heart failure, and severe valvular disease. Additionally, they found the history and exam should include assessment of functional capacity in daily life to determine cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk for major adverse cardiovascular events (MACE) or if testing is not indicated independent of planned surgery. However, cardiovascular testing may be useful in patients with poor functional capacity (e.g., unable to climb more than two flights of stairs) undergoing high-risk surgery if test results would change perioperative medical, anesthesia, or surgical approaches. Perioperative medical therapy (e.g., aspirin or statins) should be prescribed based on patient-specific risk. Careful preoperative consideration is especially important in older adults (aged ≥75 years) and patients with coronary stents, both of whom have a significantly greater risk for perioperative myocardial infarction and MACE.

“Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low (<1 percent) and higher (≥1 percent) risk of perioperative MACE during the surgical hospital admission or within 30 days of surgery,” the authors write.

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