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Cardiovasculaire risicobepaling in de eerste lijnPublished by: Domus MedicaLast published: 2020Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2010Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2020Approximately 50 million patients undergo non-cardiac surgery every year in the US.[1] Of those, about 750 per 100,000 people have a non-fatal perioperative myocardial infarction (MI). Fatal major cardiovascular and cerebrovascular events occur around 1.67% of cases.[1] Most perioperative cardiac morbidity and mortality is related to MI, heart failure, cardiogenic shock, or arrhythmias.[1]
Multiple cardiovascular risk factors are present in 45% of surgical inpatients aged ≥45 years.[2] As the global population ages, the number of patients with significant perioperative cardiac risk undergoing non-cardiac surgery can be expected to increase.
Preoperative cardiac risk assessment and perioperative management emphasise the detection, characterisation, and management of cardiac disorders in appropriate patients. Patients with known or suspected coronary artery disease (CAD), arrhythmias, history of heart failure, or current symptoms consistent with these conditions should also undergo assessment. In people aged ≥45 years, a more extensive history and physical examination is warranted.
The purpose of individual preoperative cardiac risk assessment is to:[2][3][4][5]
Assess the medical status of the patient and the cardiac risks posed by the planned non-cardiac surgery
Recommend appropriate strategies to reduce the risk of cardiac problems over the entire perioperative period, and to improve long-term cardiac outcomes.
The main overall goals of assessment are to:
Identify patients at increased risk of an adverse perioperative cardiac event (e.g., cardiovascular death, acute heart failure, MI, or haemodynamically relevant arrhythmia)
Identify patients with a poor long-term prognosis due to cardiovascular disease. Even though the risk at the time of non-cardiac surgery may not be prohibitive, appropriate treatment will affect long-term prognosis.
The nature of the evaluation should be individualised to the patient and the specific clinical scenario.
Patients presenting with an acute surgical emergency require only a rapid preoperative assessment, with subsequent management directed at preventing or minimising cardiac morbidity and death. Such patients can often be more thoroughly evaluated after surgery.
Patients undergoing an elective procedure with no surgical urgency can undergo a more thorough preoperative evaluation.
Patients are at highest risk of perioperative cardiac events in the first 30 days following surgery, but risk remains elevated for about 5 months.[5]
Consider eight steps to optimise perioperative outcomes:[6]
1. Assess clinical features
The history and physical examination should help to identify markers of cardiac risk and assess the patient's cardiac status.
High-risk cardiac conditions include recent myocardial infarction (MI), decompensated heart failure, unstable angina, symptomatic arrhythmias, and symptomatic valvular heart disease.[7]
2. Evaluate functional status
Patients who are able to exercise on a regular basis without limitations generally have sufficient cardiovascular reserve to withstand stressful operations.
3. Consider surgery-specific risk
The type of surgery has important implications for perioperative risk. Non-cardiac surgery can be stratified into high-risk, intermediate-risk, and low-risk categories (see below "risk stratification according to type of non-cardiac surgery").
4. Decide whether further non-invasive evaluation is needed
Patients who are at low cardiac risk based on clinical features and functional status, and are undergoing low-risk surgery, do not generally require further evaluation.
Patients who are at high cardiac risk based on clinical features, have poor functional status, and are being considered for high-risk non-cardiac surgery may benefit from further evaluation.
5. Decide when to recommend invasive evaluation
Indications for preoperative coronary angiography are similar to those in the non-operative setting and include patients with evidence of high cardiac risk based on non-invasive testing, angina unresponsive to adequate medical therapy, unstable angina, and proposed intermediate-risk or high-risk non-cardiac surgery after equivocal non-invasive test results.
Angiography and revascularisation are not routinely indicated for patients with stable coronary artery disease (CAD).
6. Optimise cardiovascular risk factors, lifestyle interventions, and medical therapy
Control of cardiovascular risk factors, including hypertension, dyslipidemia, and diabetes, is important before non-cardiac surgery.[3] See Essential hypertension, Hypercholesterolaemia, and Type 2 diabetes mellitus in adults.
Patients should be given optimal medical therapy, both perioperatively and in the long term, based on their underlying cardiac condition.
Lifestyle modifications before non-cardiac surgery may reduce the risk of perioperative complications, but their impact on cardiovascular complications has not been adequately studied. Smoking cessation prior to surgery has the most robust evidence base.[3][8] See Smoking cessation.
7. Perform appropriate perioperative surveillance
In patients with known or suspected CAD, the possibility of perioperative ischaemia or MI can be estimated based on the magnitude of biomarker elevation, new ECG abnormalities, haemodynamic instability, and the quality and intensity of chest pain or other symptoms.
8. Design maximal long-term therapy
Assessment for hypercholesterolaemia, smoking, hypertension, diabetes mellitus, physical inactivity, peripheral vascular disease, cardiac murmurs, arrhythmias, conduction abnormalities, and/or perioperative ischaemia may lead to evaluation and treatments that reduce future cardiovascular risk.
The patient history should be thorough and aim to:
Identify cardiac conditions (e.g., recent or past myocardial infarction, decompensated heart failure, prior unstable angina, significant arrhythmias, valvular heart disease)
Identify serious comorbid conditions (e.g., diabetes mellitus, peripheral vascular disease, stroke, renal insufficiency, pulmonary disease)
Determine patient's functional capacity
Document all current drugs, allergies, tobacco and alcohol use, and lifestyle habits (including diet and physical exercise).
On physical examination, patients should be assessed for clinical signs suggestive of cardiac disorders including: elevated jugular venous pressure, heart murmurs, and peripheral and pulmonary oedema.[9]
The functional capacity of the patient to perform common daily activities has been shown to correlate well with maximum oxygen uptake by exercise stress testing.[2] The metabolic equivalent of a task (MET) is a physiological concept expressing the energy cost of a physical activity. The MET reference values are shown below. On assessment, patients with <4 METS are considered to have poor functional capacity and are at relatively high risk of an adverse perioperative cardiac event, while patients with >10 METS have excellent functional capacity and are at very low risk of such adverse events, even if they have known coronary artery disease. Patients with a functional capacity of 4 to 6 METS or 7 to 10 METS are considered to have moderate or good functional capacity, respectively, and are generally considered at low risk of adverse perioperative cardiac events.[10]
1 MET
Eat, dress, use the toilet
Walk indoors around the house
Walk on level ground at 2 mph (3.2 km/hour)
Perform light housework such as washing dishes.
4 METs
Climb a flight of stairs (usually 18-21 steps)
Walk on level ground at 4 mph (6.4 km/hour)
Run short distances
Perform vacuuming or lift heavy furniture
Play golf or doubles tennis.
>10 METs
Swimming
Singles tennis
Basketball
Skiing.
Several risk prediction models have been developed based on data from large cohorts. Risk calculators may be used in addition to, or as an alternative to, assessment of patient-related and surgery-related risk factors. There are no data to support the use of one risk index over another; some commonly used ones are:[2]
Revised cardiac risk index (RCRI)
The revised cardiac risk index uses 6 variables to predict perioperative cardiovascular risk:[11]
High-risk surgery (intrathoracic, intra-abdominal, or suprainguinal vascular)
Ischaemic heart disease (defined as a history of myocardial infarction [MI], pathologic Q waves on the ECG, use of nitrates, abnormal stress test, or chest pain secondary to ischaemic causes)
Presence of congestive heart failure
History of cerebrovascular disease
Diabetes mellitus requiring insulin therapy
Preoperative serum creatinine level higher than 2 mg/dL.
Each of the 6 risk variables are assigned 1 point. Patients with 0, 1, or 2 risk factor(s) are assigned to RCRI classes I, II, and III, respectively. Patients with 3 or more risk factors are class IV and considered at high risk. Each class translates into 0.4% (class I), 0.9% (class II), 6.6% (class III), and 11% (class IV) risk for major cardiac events. Overall, the RCRI performs well in stratifying patients at low compared with high risk for all types of noncardiac surgery, but appears less accurate in patients undergoing vascular surgery.
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
A surgical risk calculator has been developed by the ACS NSQIP using 21 preoperative factors.[12] These factors include 20 patient characteristics (age, sex, functional class, emergency case, American Society of Anaesthesiologists class, corticosteroid use, presence of ascites within 30 days, systemic sepsis, ventilator dependence, presence of disseminated cancer, diabetes mellitus, hypertension, heart failure within 30 days, presence of dyspnoea, current smoking status, history of severe COPD, need for dialysis, presence of acute renal failure, height, and weight) and type of procedure. This model had excellent performance for mortality (c-statistic = 0.944; Brier score = 0.011 [where scores approaching 0 are better]), morbidity (c-statistic = 0.816; Brier score = 0.069), and 6 additional complications (c-statistics >0.8).[12] The ACS NSQIP surgical risk calculator offers surgeons the ability to quickly and easily estimate important, patient-specific postoperative risks and present the information in a patient-friendly format.
Vascular Study Group of New England cardiac risk index (VSG-CRI)
The VSG-CRIVSGNE risk index was developed specifically for patients undergoing vascular surgery and applies to carotid endarterectomy, lower extremity bypass, and endovascular and open repair of non-ruptured abdominal aortic aneurysms.[13] The independent predictors of adverse cardiac events (MI, arrhythmia, and heart failure, but not mortality) were increasing age, smoking, insulin-dependent diabetes mellitus, coronary artery disease, coronary heart failure, abnormal cardiac stress test, long-term beta-blocker therapy, chronic obstructive pulmonary disease, and creatinine ≥160 micromol/L (≥1.8 mg/dL). Prior cardiac revascularization was protective. The VSG-CRI predicted increasing levels of risk for cardiac events, ranging from 2.6% for the lowest risk scores (0-3) up to 14.3% for the highest risk score (7-8). This risk index performs better than RCRI for those undergoing vascular surgery.[13]
Non-cardiac surgery can be stratified according to type of surgery, into high, intermediate, or low-risk categories.[2]
High-risk surgery
Suprainguinal
Vascular
Thoracic
Transplant
Neurosurgery
Intermediate-risk surgery
General
Otolaryngology
Genitourinary
Orthopaedic
Low-risk surgery
Endocrine
Gynaecology
Obstetrics
Breast
Patients at risk of an adverse perioperative cardiac event are typically identified following history and physical examination. Patients at low risk generally require no additional testing before non-cardiac surgery. However, patients at intermediate or high risk undergoing elective non-cardiac surgery may require additional preoperative testing.
Standard laboratory testing
Standard laboratory tests such as a full blood count and renal function are recommended in patients who are undergoing intermediate- or high-risk non-cardiac surgery.[3]
Resting 12-lead ECG
Recommended for patients:[2][3]
Who are age ≥65 years
With known coronary heart disease, significant arrhythmias, other significant structural heart diseases, risk factors or symptoms of cardiovascular disease (CVD), peripheral arterial disease, or cerebrovascular disease, who are undergoing intermediate- or high-risk surgical procedures
With family history of genetic cardiomyopathy undergoing any non-cardiac surgery, regardless of age or symptoms.
Biomarkers
Brain natriuretic peptide or N-terminal pro-brain natriuretic peptide (BNP/NT-proBNP)
BNP appears to be independently predictive for major adverse cardiac events following elective vascular surgery.[14]
Use of BNP to predict cardiovascular events in the first 30 days after vascular surgery can significantly improve the predictive performance of the revised cardiac risk index.[15]
Indicated in patients with cardiovascular disease, cardiovascular risk factors (including age ≥65 years), or symptoms suggestive of cardiovascular disease, before intermediate- or high-risk non-cardiac surgery.[3]
High-sensitivity cardiac troponin T/I (hs-cTn T/I)
Can be used to rule out myocardial ischaemia prior to non-cardiac surgery, and as part of surveillance after surgery.[3]
Indicated in patients with cardiovascular disease, cardiovascular risk factors (including age ≥65 years), or symptoms suggestive of cardiovascular disease, before intermediate- or high-risk non-cardiac surgery.[3]
Echocardiography
Preoperative non-invasive evaluation of left ventricular (LV) function with transthoracic echocardiography (TTE) is reasonable or recommended for patients with:[2]
New dyspnoea
Suspected new or worsening ventricular dysfunction
Clinical signs of heart failure (HF)
Known HF with worsening dyspnoea or other change in clinical status
Other indications for TTE include patients with:[3]
Poor functional capacity and/or high NT-proBNP/BNP
Murmurs detected prior to high-risk non-cardiac surgery
Suspected new cardiovascular disease or unexplained signs or symptoms prior to high-risk non-cardiac surgery
Poor functional capacity, abnormal ECG, high NT-proBNP/BNP, or ≥1 clinical risk factor prior to intermediate-risk non-cardiac surgery
Family history of genetic cardiomyopathy
Stress testing
Used to detect inducible myocardial ischaemia.
May be considered in patients who are undergoing elevated-risk (i.e., high- or intermediate-risk) non-cardiac surgery with poor or unknown functional capacity and at higher risk for adverse perioperative cardiac events.[2]
Choice of stress testing (i.e., exercise vs. pharmacological testing) is typically based on physician and patient preferences, as well as patient factors.
Typically avoided in patients with unstable syndromes including acute coronary syndrome, decompensated HF, and aortic stenosis.
Coronary computed tomography angiography (CCTA)
May be considered for detecting high-risk coronary anatomy in patients who are undergoing elevated-risk non-cardiac surgery with poor or unknown functional capacity and at higher risk for adverse perioperative cardiac events.[2]
Coronary angiography
Indicated in patients with:
Evidence of high cardiac risk, based on non-invasive testing or CCTA
Angina unresponsive to adequate medical therapy or unstable angina
Proposed intermediate-risk or high-risk non-cardiac surgery after equivocal non-invasive test results
1. Exercise ECG
Perioperative risk stratification based on exercise ECG:
Low risk: ability to exercise moderately (4-5 METs) without symptoms; patients who can achieve >75% of maximum predicted heart rate without ECG changes.
Intermediate risk: patients with abnormal ECG response at >75% of predicted heart rate.
High risk: patients with abnormal ECG response at <75% of predicted heart rate.
2. Stress imaging
Perioperative cardiac risk stratification based on stress imaging:
More than 4 myocardial segments of redistribution indicates significant risk for adverse perioperative cardiac events.
Redistribution in 3 coronary artery territories and reversible left ventricular cavity dilation indicates higher risk of events.
Total area of ischaemia is more predictive than severity of ischaemia in a given segment.
Perioperative therapy may include:
Preoperative revascularisation with coronary artery bypass grafting or percutaneous coronary intervention
Beta-blockers
Statins
Temporary omission of other drugs (e.g., sodium-glucose cotransporter-2 [SGLT2] inhibitors, anticoagulants)
Coronary revascularisation prior to non-cardiac surgery[2]
Recommended in patients with acute coronary syndrome undergoing elective non-cardiac surgery, with deferral of surgery
May be reasonable in patients with chronic coronary disease and haemodynamically significant left main coronary artery stenosis ≥50% undergoing elective non-cardiac surgery, with deferral of surgery
Not recommended in patients with non-left main coronary artery disease undergoing non-cardiac surgery
A coronary stent is used in most percutaneous revascularisation procedures. In this case, further delay in non-cardiac surgery may be beneficial. Elective non-cardiac surgery is not recommended within 30 days of bare metal coronary stent implantation or within 6 to 12 months of drug-eluting coronary stent implantation.[2] The incremental risk of non-cardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilises at 1.0% after 6 months. Elective, high-risk, inpatient surgery, and patients with a drug-eluting stent, may benefit most from a 6-month delay after stent placement.[17]
In patients undergoing balloon angioplasty only, without coronary stent placement, non-cardiac surgery should ideally be delayed for at least 14 days post-procedure.[2]
Beta-blockers
The perioperative use of beta-blockers during non-cardiac surgery may be beneficial in reducing the risk of non-fatal myocardial infarction (MI). However, their use has also been associated with increased risk of adverse events including hypotension, bradycardia, stroke, and death.[18]
Beta-blockers should be continued in patients already on stable doses of a beta-blocker.[2][3][8]
In patients in whom new beta-blocker therapy is indicated and initiated, it may be reasonable to begin perioperative beta-blockers long enough in advance to assess safety, tolerability, and need for dose titration, preferably ≥7 days before surgery. Beta-blockers should not be started on the day of surgery.[2]
Statins
The available evidence suggests there may be a protective effect of perioperative statin use on cardiac complications such as MI, during non-cardiac surgery.[19] However, the benefit of routine use of statin therapy remains uncertain.
Therapy should be continued in patients already taking statins who are scheduled for non-cardiac surgery.[2][3][8]
Initiating a statin during the perioperative period is recommended in adult patients who meet the criteria based on their atherosclerotic cardiovascular disease (CVD) history or 10-year CVD risk.[2]
Consider temporary omission of other drugs
Guidelines recommend stopping SGLT2 inhibitors 3-4 days before elective non-cardiac surgery to reduce the risk of perioperative metabolic acidosis.[2][3]
Balancing the risks of bleeding and thrombosis for patients taking anticoagulants is a clinical challenge; multidisciplinary evaluation of the patient’s individual risk factors and circumstances is recommended.[2]
For perioperative myocardial ischaemia
Intraoperative and postoperative ST-segment monitoring can be useful to monitor patients with known coronary artery disease or those undergoing vascular surgery.
For perioperative myocardial infarction:
Postoperative troponin measurement is recommended in patients with ECG changes, or with chest pain typical of acute coronary syndrome.[2]
Surveillance is recommended with high-sensitivity cardiac troponin T/I (hs-cTn T/I) in patients with cardiovascular disease, cardiovascular risk factors (including age ≥65 years), or symptoms suggestive of cardiovascular disease undergoing intermediate- or high-risk non-cardiac surgery. Hs-cTn T/I should be measured before surgery and at 24 hours and 48 hours after surgery.[2][3]
Symptomatic aortic stenosis
Severe aortic stenosis poses a significant risk for non-cardiac surgery. Guidelines suggest that elective non-cardiac surgery should generally be postponed or cancelled in such patients.[2]
Patients require aortic valve replacement before elective but necessary non-cardiac surgery.
Asymptomatic aortic stenosis
If the aortic stenosis is severe but asymptomatic, the surgery should preferably be postponed or cancelled if the valve has not been evaluated within the previous year.[2]
Patients with left ventricular ejection fraction (LVEF) ≤50% should be considered for aortic valve replacement prior to elective non-cardiac surgery. In patients with LVEF ≥50%, the decision to delay or proceed with surgery will depend on whether it is an elevated-risk (i.e., high- or intermediate-risk) procedure.
Pulmonary hypertension
Guidelines recommend assessing patients for intermediate-risk and high-risk features of pulmonary hypertension that increase the risk of perioperative complications. Patients should be assessed by an anaesthesiologist and an expert in pulmonary hypertension, where feasible.[20]
Congenital heart disease
Patients with congenital heart disease, especially those with unrepaired lesions or a residual lesion burden and compromised cardiovascular status, require individualised perioperative management. The American Heart Association/American College of Cardiology (AHA/ACC) guidelines for managing adults with congenital heart disease recommend a stepwise approach to preoperative cardiac assessment.[21][22]
Patients on psychotropic drugs[23]
Antidepressant treatment for patients with depression should not be discontinued prior to non-cardiac surgery.
Patients chronically treated with a tricyclic antidepressant should undergo cardiac evaluation prior to non-cardiac surgery.
Irreversible monoamine oxidase inhibitors (MAOIs) should be discontinued at least 2 weeks prior to non-cardiac surgery and be replaced with a reversible MAOI to avoid relapse of the underlying condition.
The incidence of postoperative confusion is significantly higher in patients with schizophrenia if drug treatment is discontinued prior to surgery. Thus, antipsychotics should be continued perioperatively in patients with chronic schizophrenia.
Lithium administration should be stopped 72 hours before surgery. It can be restarted afterwards if the patient has normal ranges of electrolytes, is hemodynamically stable, and is able to eat and drink.
Preoperative assessment of older surgical patient[24]
Data from the US National Hospital Discharge Survey demonstrate increasing hospital utilisation by older people.[25][26] In response to the need for quality improvement in perioperative geriatric surgical care, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society formulated practice guidelines to ensure optimal care of the geriatric surgical patient.[24] The guideline development panel prioritised a number of preoperative domains specific to older individuals (e.g., cognitive impairment, frailty, polypharmacy) and, additionally, issues commonly encountered in this population (e.g., risk of malnutrition, lack of family or social support). Consensus statements and evidence-based recommendations for improving the preoperative assessment of the geriatric surgical patient were summarised in a checklist:[24]
Perform a complete history and physical examination
Assess cognitive ability and capacity to understand the anticipated surgery
Screen for depression
Identify and document risk factors for developing postoperative delirium
Screen for alcohol and other substance abuse/dependence
Perform a preoperative cardiac evaluation according to local guidance for patients undergoing non-cardiac surgery (e.g., American College of Cardiology/American Heart Association, European Society of Cardiology/ European Society of Anaesthesiology)[2][27]
Identify risk factors for postoperative pulmonary complications and implement preventive strategies
Document functional status and history of falls
Determine baseline frailty score
Evaluate nutritional status and consider preoperative interventions if the patient is at severe nutritional risk
Document drug history and consider appropriate perioperative adjustments. Monitor for polypharmacy
Determine the patient's treatment goals and expectations in the context of the possible treatment outcomes
Determine the patient's family and social support system
Order appropriate preoperative diagnostic tests focused on older patients.
(Adapated from: Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215:453-466.[24])
American College of Cardiology (ACC)/American Heart Association (AHA)
2024 Guideline for perioperative cardiovascular management for noncardiac surgery: a report of the ACC/AHA joint committee on clinical practice guidelines ACC/AHA: guideline for perioperative cardiovascular management for noncardiac surgery Opens in new window
European Society of Cardiology (ESC)
2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery ESC: guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery Opens in new window
Canadian Cardiovascular Society
Guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery CCS: guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery Opens in new window
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