- 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:
- Balloon angiography: 2 weeks
- Bare metal stent: 1 month
- DES / DAPT: 1 year (180 days if delay risk is greater than ischemia risk)
RCRI Risk Factors: DM, HF, CAD, CRI, stroke
- 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
- 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.
- Measure troponins if suggestion of myocardial ischemia / MI.
- EKG if MI, ischemia, or arrhythmias.
- No routine troponins pre0p
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e77–137.
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