Optimizing perioperative cardiac risk assessment and management for noncardiac surgery


Background: There are extensive publications regarding preoperative risk assessment and optimization of risk management. This article is a review of current aggregate data from various meta-analyses and observational studies. It explores a systematic approach to preoperative risk assessment.

Dr. David Young, Division of Hospital Medicine, Northwestern University, Chicago

Dr. David Young

Study design: Literature review of meta-analyses and observational studies.

Setting: A review of the current literature available in the MEDLINE database and Cochrane Library from 1949 to January 2020, favoring meta-analyses and clinical practice guidelines.

Synopsis: A total of 92 publications were included in this review, which found history, physical exam, and functional capacity to be the best assessments of cardiac risk and should guide further preoperative management. Cardiovascular testing is rarely indicated except in those with clinical signs and symptoms of active cardiac conditions or with poor functional status undergoing high-risk surgery. Cardiac consultation should be considered for those with prior stents; high-risk conditions, including acute coronary syndrome, severe valvular disease, or active heart failure, among other conditions; or high-risk findings on cardiovascular testing. Preoperative medications should be individualized to patient-specific conditions. This study is limited by current available evidence and expert opinion, and the systematic approach suggested here has not been prospectively tested.

Bottom line: Preoperative risk assessment and management should be largely based on individualized history, physical exam, and functional status. Cardiovascular work-up should be pursued only if it would influence surgical decision-making and perioperative care.

Citation: Smilowitz NR, Berger JS. Perioperative cardiovascular risk assessment and management for noncardiac surgery: A review. JAMA. 2020 Jul 21;324:279-90. doi: 10.1001/jama.2020.7840.

Dr. Young is a hospitalist at Northwestern Memorial Hospital and instructor of medicine, Feinberg School of Medicine, both in Chicago.

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