Perioperative Cardiovascular Assessment

Definition

A structured, stepwise framework for evaluating and managing cardiovascular risk in adult patients (≥18 years) undergoing noncardiac surgery (NCS). The goal is to identify patients who warrant further evaluation or optimisation before surgery, avoid unnecessary testing in low-risk patients, and ensure cardiovascular comorbidities are appropriately managed throughout the perioperative period.

Key Concepts

Surgical Risk Classification

• Emergency (<2h): No preoperative evaluation feasible; manage cardiac conditions perioperatively
• Urgent (2–24h): Limited time for targeted risk reduction
• Time-sensitive (up to 3 months delay): Allows evaluation and optimisation
• Elective: Full preoperative evaluation can occur
• Low risk: Predicted MACE <1%; Elevated risk: MACE ≥1% (traditionally RCRI >1)
• Highest-risk procedures: suprainguinal vascular, thoracic, transplant, neurosurgery
• Intermediate-risk: general, genitourinary, orthopaedic
• Lowest-risk: endocrine, breast, gynaecology/obstetrics (sources/periop-aha-2024, rating: very high)

Stepwise Assessment Algorithm (Figure 1, AHA 2024)

1. Emergency surgery? → Proceed; manage cardiac conditions perioperatively
2. Active cardiac conditions? (ACS, decompensated HF, severe symptomatic AS, unstable arrhythmia) → Evaluate and treat first
3. Low-risk surgery? → Proceed without further cardiac testing
4. Assess functional capacity using DASI and calculate perioperative risk with RCRI or NSQIP
5. If elevated risk + poor/unknown functional capacity → consider biomarkers, ECG, selective non-invasive imaging
6. Shared decision-making; proceed with surgery ± GDMT optimisation (sources/periop-aha-2024, rating: very high)

Cardiovascular Risk Indices

• RCRI (Revised Cardiac Risk Index): 6 predictors (ischaemic heart disease, cerebrovascular disease, HF, insulin-dependent diabetes, creatinine ≥2.0 mg/dL, high-risk surgery); 1 point each; RCRI ≤1 = low risk. COR 2a.
• NSQIP MICA: 5-variable model; ROC 0.88; incorporates procedure type and functional status
• Universal NSQIP Surgical Risk Calculator: 21 components; best discriminatory performance (ROC 0.90)
• AUB-HAS2: 6 items; low (0–1), intermediate (2–3), high (>3) 30-day risk
• No single risk index recommended over others; combining RCRI with coronary calcium from existing CT may enhance stratification (sources/periop-aha-2024, rating: very high)

Functional Capacity Assessment

• Measured in METs; threshold of <4 METs = poor functional capacity
• DASI (Duke Activity Status Index): 12-item validated self-report tool (score range 0–58.2); DASI ≤34 predicts increased 30-day death or MI — COR 2a (B-NR)
• Subjective clinician assessment of METs is NOT associated with outcomes (METs trial, n=1401)
• DASI added to RCRI significantly improves predictive performance (BASEL-PMI: functional capacity <2 flights of stairs → 1.63× 30-day MACE)
• Poor functional capacity alone does not mandate preoperative stress testing (sources/periop-aha-2024, rating: very high)

Frailty

• COR 2a: Validated frailty assessment for all patients ≥65 years (or <64 with perceived frailty) undergoing elevated-risk NCS
• Frailty → 3.71× increased 30-day mortality and 2.39× increased 30-day complications (meta-analysis, 1.1 million patients)
• Validated tools: Fried Phenotype, Clinical Frailty Scale (best predictor in NCS), FRAIL Scale, Edmonton Frail Scale, SPPB
• Prehabilitation (exercise + nutrition) may improve outcomes in selected frail patients (sources/periop-aha-2024, rating: very high)

Preoperative Biomarkers

• BNP/NT-proBNP (COR 2a, B-NR): In patients with CVD, age ≥65, or age ≥45 with CVD symptoms undergoing elevated-risk NCS
  • Abnormal thresholds: BNP >92 ng/L; NT-proBNP ≥300 ng/L
  • NT-proBNP >100 pg/mL independently predicts all-cause mortality (VISION substudy)
  • Addition of NT-proBNP to traditional risk scores did not significantly improve prediction beyond scores + functional status in one cohort (n=3597)
• Cardiac troponin (COR 2b, B-NR): Same population as BNP; provides baseline for postoperative interpretation; no management change warranted on elevated preoperative cTn alone
• No studies demonstrate that acting on elevated preoperative biomarkers improves outcomes (sources/periop-aha-2024, rating: very high)

Preoperative 12-Lead ECG

• COR 2a: Patients with known coronary disease, arrhythmia, PAD, cerebrovascular disease, structural heart disease, or active CVD symptoms undergoing elevated-risk surgery
• COR 2b: Asymptomatic patients undergoing elevated-risk surgery without known CVD
• COR 3 No Benefit: Routine ECG in asymptomatic patients undergoing low-risk procedures
• Actionable findings: Mobitz II+ AV block, new-onset AF, QT prolongation (inform anaesthetic/antibiotic choice), new bundle branch block (sources/periop-aha-2024, rating: very high)

Stress Testing

• COR 2b (B-NR): Only if poor/unknown functional capacity AND elevated validated risk AND suspicion of high-risk ischemia (left main/multivessel disease) undergoing elevated-risk surgery
• COR 3 No Benefit (B-R): Low-risk patients, adequate functional capacity, or low-risk surgery
• An abnormal stress test should NOT prompt angiography unless it shows high-risk features (LM disease or severe multivessel + reduced EF)
• CARP trial (n=510): Preoperative coronary revascularisation did not reduce 30-day MI or mortality vs medical therapy before vascular surgery (sources/periop-aha-2024, rating: very high)

Coronary CT Angiography (CCTA)

• COR 2b: Elevated risk + poor/unknown functional capacity only if high-risk coronary anatomy suspected; provides high negative predictive value
• COR 3 No Benefit: Routine CCTA; contraindicated in urgent/emergency surgery
• CCTA overestimates risk in patients who will NOT have MACE (5× more false-positive than false-negative)
• Coronary calcium score 0 within 2 years → proceed without additional cardiac testing (sources/periop-aha-2024, rating: very high)

Invasive Coronary Angiography

• COR 3 No Benefit (C-LD): Routine preoperative ICA not recommended regardless of surgical risk
• ICA reserved for patients with ACS, accelerating angina despite GDMT, newly diagnosed moderate-severe ischemia on stress testing, or indicators of obstructive left main disease (sources/periop-aha-2024, rating: very high)

Perioperative Blood Pressure Management

• Intraoperative (COR 1, B-NR): Maintain MAP ≥60–65 mmHg or SBP ≥90 mmHg
  • Harm threshold: MAP <65 or SBP <90 sustained ~15 minutes
  • POISE-3 (n=7490): No benefit from targeting MAP ≥80 vs MAP ≥60 mmHg
• Postoperative (COR 1, B-NR): Treat hypotension (MAP <60–65 or SBP <90) promptly
• Preoperative: May defer elective elevated-risk surgery if SBP ≥180/DBP ≥110 + ≥1 RCRI risk factor (COR 2b)
• Continue antihypertensives throughout perioperative period in most patients (COR 2a)
• Restart antihypertensive medications as soon as clinically reasonable postoperatively (COR 1) (sources/periop-aha-2024, rating: very high)

MINS: Myocardial Injury After Noncardiac Surgery

• Definition: Elevated postoperative cTn (>99th percentile URL) of presumed ischaemic origin, regardless of symptoms; includes type 1 and type 2 MI; asymptomatic in 80–90%
• Incidence: ~20% of patients undergoing NCS
• Prognosis: 30-day mortality ~10%; proportional to peak cTn concentration (17% in highest quartile vs 1% in lowest); 34% population attributable risk of 30-day postoperative mortality
• Elevated postop cTn without ischaemic feature → 3× 30-day mortality hazard; with ischaemic feature → 5× hazard (VISION, n=21,842)
• Surveillance (COR 2b, B-NR): cTn at 24h and 48h post-surgery in patients with known CVD, CVD symptoms, or age ≥65 with risk factors undergoing elevated-risk NCS; NOT in low-risk NCS (COR 3)
• Management:
  • COR 2a: Cardiology consultation and GDMT optimisation (early referral → reduced 30-day mortality)
  • COR 2b: Consider antithrombotic therapy — MANAGE trial: dabigatran 110 mg BID reduced major vascular events but increased minor/GI bleeding; high dropout rate
  • Algorithm: elevated postop troponin → evaluate for ischaemic symptoms/ECG changes → classify as MINS vs STEMI/NSTEMI vs nonischaemic injury
  • Nonischaemic causes to exclude: pulmonary embolism, sepsis, decompensated HF, stroke (sources/periop-aha-2024, rating: very high)

Postoperative MI Management

• Perioperative MI incidence 0.9–15%; predominantly type 2 MI (supply-demand mismatch)
• Perioperative STEMI: in-hospital mortality 30–35%; emergent ICA strongly considered (team decision: surgeon + anaesthesiologist + cardiologist)
• Perioperative NSTEMI: GDMT as per spontaneous MI; ICA in selected patients balancing bleeding vs thrombotic risk
• Management decisions require multidisciplinary team input (sources/periop-aha-2024, rating: very high)

Perioperative Pharmacotherapy Summary

Anticoagulation Management

• Most patients with AF on DOACs: time-based interruption without bridging
• DOAC interruption: factor Xa inhibitors ≥3–5 days (depending on renal function and bleeding risk); dabigatran ≥4–6 days (CrCl <50)
• VKA bridging: only for very high thrombotic risk (mechanical mitral valve, recent VTE <1 month) — BRIDGE trial confirmed no benefit in most AF patients
• DOAC resumption: as early as 6h postoperatively if haemostasis achieved (sources/periop-aha-2024, rating: very high)

Intraoperative Management

• Anaesthetic technique (volatile vs TIVA, neuraxial vs general): no meaningful difference in cardiovascular outcomes
• Thoracic epidural analgesia: reduces perioperative MI in major abdominal surgery (COR 2a)
• Tranexamic acid: reduces blood loss and transfusions in NCS with expected blood loss (COR 2a); caution in cardiovascular high-risk patients
• IV iron: COR 2a for iron-deficiency anaemia before elective NCS
• TEE/FoCUS: COR 2a for unexplained haemodynamic instability; NOT routine monitoring
• PA catheter: COR 3 No Benefit for routine use (sources/periop-aha-2024, rating: very high)

Special Populations: Patients with CIEDs

• Periprocedural CIED management requires dedicated multidisciplinary planning separate from the general perioperative cardiovascular assessment framework (sources/periop-cied-aha-2024, rating: high)
• Preprocedural screening should identify CIED type, manufacturer, pacing dependency, battery status, and anticipated EMI sources before any invasive procedure (sources/periop-cied-aha-2024, rating: high)
• Key distinction: magnet application to an ICD does not affect pacing function — pacing-dependent ICD patients require device reprogramming, not just magnet placement (sources/periop-cied-aha-2024, rating: high)
• Medtronic Micra leadless pacemaker has no magnet response — pacing-dependent patients with Micra require reprogramming to asynchronous mode (VOO) before procedures with EMI above the umbilicus (sources/periop-cied-aha-2024, rating: high)
• Critical postprocedural step: re-enable ICD therapies before discharge from monitored setting — patient deaths have been reported following failure to do so (sources/periop-cied-aha-2024, rating: high)
• See concepts/Periprocedural-CIED-Management for the full device-specific framework

Contradictions / Open Questions

• No RCTs have shown that managing elevated preoperative biomarkers (BNP, troponin) improves outcomes — uncertain value of biomarker-guided preoperative management
• Optimal perioperative BP thresholds: POISE-3 does not support higher intraoperative BP targets vs MAP ≥60 mmHg, but INPRESS suggested benefit from tighter control — conflicting evidence
• Perioperative management of sacubitril/valsartan (ARNI) is completely unstudied
• GLP-1 agonist guidance based on ASA consensus only, not RCT data
• Optimal MINS management strategy remains undefined — MANAGE trial had significant limitations (high dropout, post-hoc primary outcome change)
• Optimal surveillance strategy for postoperative AF after NCS not established

Connections

• Related to concepts/Periprocedural-CIED-Management — specialized framework for pacemakers, ICDs, CRT, and ILR perioperative management
• Related to entities/Heart-Failure — perioperative HF management; SGLT2i discontinuation
• Related to entities/Atrial-Fibrillation — perioperative AF; new-onset POAF stroke risk
• Related to entities/Pulmonary-Hypertension — continue PAH therapy; specialised centre referral
• Related to entities/HCM — avoid LVOT aggravating factors
• Related to concepts/Aortic-Stenosis — perioperative AS algorithm; TAVI before NCS
• Related to concepts/Mitral-Stenosis — perioperative MS management
• Related to concepts/TAVI — NCS timing after TAVI
• Related to concepts/DAPT-Strategies — PCI timing and perioperative antiplatelet management
• Related to entities/Chronic-Coronary-Disease — preoperative revascularisation thresholds

Sources

• sources/periop-aha-2024
• sources/periop-cied-aha-2024