Perioperative Guidelines 2014 Update – Synopsis

  • 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


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



  • 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

  • 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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