43. Assessment of Patients with Heart Disease for Fitness for Noncardiac Surgery

The basic tenet in preoperative evaluation remains that information regarding the extent and stability of disease will effect patient management and lead to improved outcome. The history should focus on cardiovascular risk factors and symptoms or signs of unstable cardiac disease states. Six independent predictors of complications have been identified: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/day, with increasing cardiac complication rates noted with increasing number of risk factors. In 2009, the American College of Cardiology/American Heart Association produced guidelines which include an algorithm to determine the indication for further diagnostic evaluation which incorporates clinical risk, surgical procedure risk, and exercise capacity. Current evidence suggests that further risk stratification in this group of patients considered at intermediate risk based on clinical history alone was unnecessary as long as perioperative beta-blockers were used, while those patients with left main disease may benefit from testing. The current evidence does not support the use of percutaneous coronary interventions beyond established indications for nonoperative patients, while advocates continuing aspirin therapy in all patients with a coronary stent and discontinuing clopidogrel for as short a time interval as possible. With respect to perioperative medical therapy, current evidence supports the continuation of beta-blockers and statins.