Perioperative Guidelines 2014 Update – Synopsis

Wait ≥ 60 days after MI prior to non cardiac surgery in the absence of coronary intervention.

Age > 62 yo is an independent risk factor for perioperative stroke.

Perioperative Valvular Disease Considerations:

Patients with moderate-severe stenosis or regurgitation need an echo if none in the last year or changes in clinical status or physical exam.
In patients that meet indications for valvular surgery, valvular intervention (replacement/repair) reduces perioperative risk.
Asymptomatic severe AS may receive elective non-cardiac surgery (elevated risk).
Asymptomatic severe MS may receive elective non-cardiac surgery (elevated risk), if balloon MV-plasty not possible.
Asymptomatic severe AI with normal LVEF may receive elective non-cardiac surgery (elevated risk)
Asymptomatic severe MR may receive elective non-cardiac surgery (elevated risk)

ICD management plan should be discussed between surgeon and “clinician” prior to non-cardiac surgery.

Patients with pulmonary HTN should have PH specialist, and should continue usual pulmonary vascular therapy.

Pre-Surgical Cardiac Testing:

Go to surgery: surgical emergency, low-risk surgery (< 1%), > 4 METS.
Stress testing: < 4 METS, unknown functional capacity. Not useful for low risk surgery or > 4 METS.
EKG: useful for CAD, arrhythmias, PAD, cerebrovascular disease, structural HD. Not useful for low-risk surgery & asymptomatic.
LVEF: unknown dyspnea on exertion, HF with change of symptoms, HF with no echo for 1 year. Not useful for routine use.
Cardiopulmonary Testing: elevated risk surgery & unknown functional capacity.
Coronary Angiography: routine use not needed. Ok to revascularize if it is indicated anyways.

Post-PCI Recommendations to Delay Surgery:

RCRI Risk Factors: DM, HF, CAD, CRI, stroke

Medical Therapy:

Beta blockers: ok to continue peri-op, ischemia risk, 3+ RCRI risk factors. Don’t start on day of surgery.
Statins: ok to continue in surgery, start for vascular surgery, possibly for elevated-risk procedures
Alpha-2 Agonists not helpful to prevent cardiac events
ACEI: ok to continue periop, ok to start soon post-op
DAPT for stent:
Continue DAPT 4-6 weeks after BMS or DES if benefit > risk
If surgery mandates P2Y12 discontinuation, continue ASA and restart P2Y12 ASAP
DAPT management should be a partnership with surgeon, cardiologist, and patient
No need to start ASA for elective non-cardiac non-carotid surgery with no previous stent

Anesthesia

Neuraxial anesthesia for AAA surgery
Epidural anesthesia for hip fracture
TEE for evaluation of hemodynamic instability, not for routine use
Hemodynamic assist devices can be used for acute severe cardiac dysfunction
Pulmonary artery catheterization for hemodynamic abnormalities that cannot be resolved before surgery. No routine use.

Perioperative Surveillance

References: