CV risk assessment before noncardiac surgery may predict perioperative outcomes
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CV risk should be comprehensively assessed before noncardiac surgery, including a thorough history and physical examination, researchers found in a review.
The review by Nathaniel R. Smilowitz, MD, MS, assistant professor and interventional cardiologist at NYU Langone Health, and Cardiology Today Editorial Board Member Jeffrey S. Berger, MD, MS, associate professor of medicine and surgery and co-director at the Center for the Prevention of Cardiovascular Disease at NYU Langone Health, was published in JAMA.
Perioperative CV risk reduction
Smilowitz and Berger reviewed studies published between January 1, 1949 and January 27, 2020 to find available evidence on risk assessment, testing and optimal medical therapy for the reduction of perioperative CV risk before noncardiac surgery.
History and a focused CV physical examination should be a starting point for evaluating perioperative risk and focus on major adverse CV events such as HF, ischemic heart disease, valvular heart disease and hypertension, Smilowitz and Berger wrote, noting patients should also be asked whether they can perform workloads of four or more metabolic equivalents without symptomatic limitation.
Risk calculators including the Revised Cardiac Risk Index can also be used to determine whether a patient has low or high risk for perioperative major adverse CV events during admission or up to 30 days after surgery. Patients with higher risk may undergo stress testing if the results would possibly change certain approaches involved in surgery such as anesthesia, according to the authors.
Routine coronary revascularization does not improve perioperative outcomes as it does not reduce perioperative risk. One trial included in the review found that patients who underwent revascularization did not have differences in postoperative MI within 30 days or long-term mortality compared with those who did not undergo revascularization.
Low-dose aspirin after surgery does not decrease CV events but may increase surgical bleeding, according to the review. In a trial included in this review, patients who were assigned preoperative aspirin did not have lower rates of MI or death compared with those assigned placebo. In addition, patients assigned aspirin had increased rates of major bleeding.
According to the authors, statins should be considered after surgery for patients with atherosclerotic CVD who are undergoing vascular surgery. A study found that statin therapy was linked with fewer CV complications post-surgery and lower mortality compared with those not taking statins (1.8% vs. 2.3%; P < .001). In contrast, high doses of beta-blockers given between 2 and 4 hours before surgery can increase the risk for stroke (1% vs. 0.5%; P = .005) and mortality (3.1% vs. 2.3%; P = .03) compared with patients who were not taking beta-blockers.
The risk for MI after surgery and other major adverse CV events is elevated in patients aged 75 years and older compared with younger patients (9.5% vs. 4.8%; P < .001), Smilowitz and Berger wrote, noting this risk is also increased in patients with coronary stents compared with those without these stents (8.9% vs. 1.5%; P < .001).
Review limitations
“This review has some limitations,” Smilowitz and Berger wrote. “First, a separate systematic literature search was not performed for each subcategory discussed. Therefore, some relevant studies may have been missed. Second, perioperative care guideline recommendations are limited by the quality of the available evidence and often rely on expert opinion.”
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