Updated Guidelines on Preoperative Cardiac Risk Assessment

Hospitalists often encounter an increasing number of patients with cardiac disease and complex illnesses who need noncardiac surgery. Approximately one in 33 patients over the age of 45 experiences perioperative cardiovascular complications (major adverse cardiovascular events [MACEs]).¹ Babar Junaidi, MD, associate site director for hospital medicine at Emory University Orthopedic and Spine Hospital, summarized the American Heart Association’s (AHA’s) updated guidelines on cardiac risk assessment and simplified cardiac risk stratification into a seven-step approach.²

Step One

Review medical history for any cardiovascular risk factors and determine the urgency of the surgery. If the procedure is emergent (within two hours), proceed with surgery and review any cardiac risk factors that could contribute to post-operative complications. Otherwise, proceed to step 2.

Step Two

Evaluate for acute cardiac diseases, including acute coronary syndromes, acute decompensated heart failure, or unstable cardiac arrhythmias. Treat these conditions before pursuing surgery. Decision making about deferral of surgery, non-operative management, or initiation of palliative measures should be shared with surgeons and patients.

Step Three

Review medical history and assess for modifiable risk factors: valvular heart disease, pulmonary hypertension, congenital heart disease, coronary artery disease, pacemaker, recent stroke, and frailty. Frailty—physiologic decline affecting multiple organ systems—is independently associated with worse outcomes. A recent comparison study of scoring systems showed the Clinical Frailty Scale to be superior.³ If modifiable risk factors are present, refer to specialists for optimization.

Step Four

Quantify the postoperative risk of major adverse cardiovascular events, e.g., acute myocardial infarction, arrhythmias, cardiac death, or acute heart failure exacerbations. There are several validated risk calculators to evaluate for this. The Revised Cardiac Risk Index (RCRI), available since 1999, is well-validated but only focuses on cardiac complications.⁴ The National Surgical Quality Improvement Project (NSQIP) surgical risk calculator assesses more than 15 factors for a more comprehensive risk assessment of complications.⁵ AUB-HAS2 is a newer scoring system suggested by the AHA.⁶ If the patient is deemed low risk, proceed with surgery; otherwise, continue to the next step.

Step Five

Determine the patient’s functional capacity. Traditionally, we evaluate how many Metabolic Equivalent of Tasks (METs) a patient can perform, but this is subjective, and clinicians may overestimate patients’ functional capacity. DASI (Duke Activity Status Index) is more objective.⁷ If the patient has poor functional status, we should determine if further testing would have an impact on their care. If yes, proceed to the next step.

Step Six

Check cardiac biomarkers preoperatively, including NT pro-B-type natriuretic peptide (NT-proBNP) and troponin. Preoperatively elevated NT-proBNP is associated with a higher risk of cardiovascular death at 30 days, a predicted risk of myocardial infarction, and a risk of all-cause mortality. If cardiac biomarkers are elevated, talk to surgical teams and patients about the potential need to pursue additional cardiac testing. If these tests are concerning, proceed to step 7.

Step Seven

If the patient had elevated biomarkers, we should consider non-operative or palliative options. However, if a decision is made to proceed with surgery, then we should monitor postoperative troponin levels twice per day for the next few days to evaluate for myocardial injury after non-cardiac surgery (MINS). MINS is any troponin increase greater than the 99th percentile of the upper limit of normal, and includes type 1 and type 2 myocardial infarction. Risk factors include older age, poor functional status, male sex, diabetes, hypertension, history of cerebrovascular accident, heart failure, atrial fibrillation, and specific lab findings (high pre-op glucose, elevated BNP, elevated neutrophil:lymphocyte ratio); surgical risk factors are high-risk surgery and/or emergency surgery. MINS is suspected to result from the interplay of perioperative physiologic events, including inflammatory cytokine release, platelet activation, coagulation cascade activation, cortisol surge, and fluid shifts. These can lead to hemodynamic instability and demand-supply mismatch, cardiac stress, and troponin elevation. Since MINS is associated with increased post-operative mortality, clinicians must diagnose MINS and treat any underlying cause, if known. In the absence of any clear triggers, one study showed that patients initiated on statin therapy had lower mortality.⁸

An echocardiogram is not routinely recommended as pre-op testing, but may be indicated for patients with poor functional status or symptoms of cardiac disease. Obtaining a preoperative echocardiogram may delay surgery and/or increase the length of stay and mortality.⁹

Pre-operative stress testing can be considered in patients with functional impairment, but the positive predictive value is similar to that of a pre-operative BNP. While reversible ischemia is associated with increased complications, revascularization may not always impact long-term outcomes. Revascularization is important for patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, left main coronary disease, or refractory symptoms despite guideline-directed medical therapy.

Dr. Agrawal

Ms. Carpinello

Dr. Agrawal is an assistant professor in the division of hospital medicine at the Emory University School of Medicine and a hospitalist at Emory University Hospital, both in Atlanta. Ms. Carpinello is a nurse practitioner-hospital medicine advanced practice practitioner at Emory Healthcare and a nocturnist at Emory University Hospital, both in Atlanta.

References

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3. McIsaac DI, et al. Prospective comparison of preoperative predictive performance between 3 leading frailty instruments. Anesth Analg. 2020;131(1):263-272. doi:10.1213/ANE.0000000000004475.
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8. Park J, et al. Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery. Sci Rep. 2020;10(1):11616. doi:10.1038/s41598-020-68511-3.
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