Cardiac Risk of Noncardiac Surgery: Clinical Risk Assessment
M
ajor perioperative cardiac events are estimated to complicate between 1.4% and
3.9% of the more than 50 million surgical procedures performed annually in the United
States. Given that the great majority of surgeries
are elective, that means there is an opportunity to
implement strategies to reduce this risk.
Recently in JACC, Akshar Patel, MD, and Kim
Eagle, MD both from the University of Michigan
Medical School, Ann Arbor, MI, and Prashant
Vaishnava, MD, Mount Sinai Heart in New York
City, NY wrote a review covering “Cardiac Risk of
Noncardiac Surgery.”1 They discussed important
features of the initial preoperative clinical risk
assessment, indications for diagnostic testing to
quantify cardiac risk, and methods and indications
for pre-emptive therapies.
According to Valentin Fuster, MD, PhD, the
editor-in-chief of JACC, “The subject is important
for two reasons: the cardiac risk from noncardiac
surgery is in front of us every day; and the second
one, which is critical, is the patient has to be
informed of the pros and cons of how we manage
his or her situation and their risk of perioperative
cardiac events including all noncardiac events,
including mortality.”
The perioperative incidence of major adverse
cardiac events is, first and foremost, related to base-
line risk. For many patients, their surgery may not
be cardiac-related but they already have cardiovascular conditions that put them at higher risk. Here
is the number to remember: An estimated 85.6 million American adults (more than one in three) have
one or more types of cardiovascular disease (CVD).2
Because of overlap across conditions, it is impossible to add these conditions to arrive at a total,
but here are the current individual estimates2:
Aside from the presence of CVD, the type
of surgery the patient will undergo contributes
substantially to the perioperative cardiac risk.
Consequently, proper risk assessment is important.
One source of clinical guidance is the 2014 ACC/
AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing
Noncardiac Surgery.3
PREOPERATIVE RISK ASSESSMENT
• Congenital heart disease: 750,000 survivors
with simple lesions, 400,000 with moderate lesions, and 180,000 with complex lesions (most
optimistic estimation); in addition, 3.0 million
people in the U.S. have bicuspid aortic valves
• Coronary artery disease: 15.5 million
• Heart failure: 5.7 million (≥ 20 years of age)
• Hypertension: 80.0 million
• Peripheral artery disease: 8.5 million (≥ 40
years of age)
• Stroke: 6.6 million
• Valve disease: 7.97 million
Several multivariate risk indexes may be helpful forpreoperative assessment. The Revised Cardiac Risk
Index (RCRI) is, perhaps, the
most well-known as well as the
simplest tool. Other risk prediction tools include those of the
American College of Surgeons
(ACS) and the National Surgical
Quality Improvement Program (NSQIP), the Myocardial
To listen to an interview with Valentine
Infarction and Cardiac Arrest
Fuster, MD, PhD, on
(MICA), and the ACS NSQIP
the cardiac risk of
Surgical Risk Calculator.
non-cardiac surgery,
scan the code or visit
Patel et al. noted that cardithe CSWN Youtube
ac risk in noncardiac surgery
channel at youtube.
patients is best tackled by a
com/user/CSWNews.
perioperative team approach,
utilizing the collaborative
efforts and shared decision
making of the patient, primary caregiver, cardiologist,
surgeon, and anesthesiologist.
That team approach, they
noted, is key to ensuring proper implementation of
current evidence-based guidelines.
As the authors of the JACC review wrote, “Accurate identification of patients at risk may not only
help to better inform patients about the benefit-torisk ratio of procedures, but also guide the allotment
of limited clinical resources, utilization of preventive
interventions, and areas of future research.”
(Editor’s note: Follow the references below to
access the paper by Patel, Eagle, and Vaishnava.
The paper’s central illustration features a decision
tree to use when considering noncardiac surgery.
The graphic details key considerations in the determination and treatment of perioperative cardiac risk of
noncardiac surgery and provides crucial facts regarding common risk factors. It lists, in succinct snippets,
the effectiveness of various possible therapeutic
interventions and the overall algorithm could help
you determine the appropriate level of preoperative
cardiac testing in individual patients.)
REFERENCES:
1. Patel AY, Eagle KA, Vaishnava P. J Am Coll Cardiol.
2015;66:2140-8.
2. Mozaffarian D, Benjamin EJ, Go AS, et al. Circulation.
2016;133:e38-e360.
3. Fleisher LA, Fleischmann KE, Auerbach AD, et al.
J Am Coll Cardiol. 2014;64:e77-e137.
ACC.org/CSWN
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