Perioperative cardiac risk during non-cardiac surgery
THE CONTEXT
Non-cardiac surgery can precipitate myocardial infarction and death in patients with coronary artery disease or other heart disease, particularly during major vascular, abdominal or thoracic operations.
Assessment and coronary risk
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Preoperative cardiac assessment helps weigh individual benefit against risk and identify measures to reduce operative risk.
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The normal surgical response includes a hypercoagulable state that may promote coronary thrombosis and an early postoperative acute coronary syndrome.
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Patients with recent PCI or acute coronary syndrome are at greatest risk. Whenever possible, elective non-cardiac surgery should be avoided for 3 months after either event.
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Antiplatelet, statin and β-blocker therapies should be continued throughout the perioperative period where possible.
Fluid balance and valvular disease
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Surgery normally stimulates vasopressin release. Excessive intravenous fluids can readily precipitate heart failure in patients with impaired left ventricular function or valvular heart disease, making careful fluid balance essential during and after surgery.
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Severe aortic or mitral stenosis increases risk because patients may be unable to increase cardiac output in response to surgical stress.