This transcript has been edited for clarity.
In primary care, we frequently receive requests to conduct thorough preoperative evaluations for patients slated for surgical procedures. In this discussion, I will delve into the recently updated American Heart Association and American College of Cardiology guideline for perioperative cardiovascular management for noncardiac surgery (NCS).
The most crucial aspect is to adopt a methodical approach to determine whether a patient’s surgery can proceed as originally planned or, although infrequent, when it becomes imperative to postpone the operation for a more comprehensive assessment and/or treatment. Another significant consideration involves understanding how and when to temporarily halt commonly prescribed medications prior to surgical intervention.
Surgical Procedures and Degree of Risk
When evaluating perioperative cardiac risk, two primary factors must be taken into account: the inherent risk associated with the surgical procedure itself and the patient’s pre-existing cardiovascular risk. Among high-risk NCSs, procedures such as vascular, thoracic, transplant, and neurosurgeries hold particular concern. Intermediate-risk surgeries encompass fields like general surgery, otolaryngology, genitourinary, and orthopedic interventions. On the lower end of the risk spectrum, surgeries classified as low-risk include endocrine, breast, gynecology, and obstetric procedures, while very low-risk options might involve cataract and other ophthalmological surgeries, dental work, endoscopic examinations, and superficial skin biopsies.
Despite frequently assisting with preoperative evaluations for low-risk surgeries, the guideline specifying, “Little evidence exists to support extensive preoperative testing in patients planned for low-risk surgeries….This is particularly true for very low-risk procedures,” should be kept in mind.
The initial — and arguably most pivotal — step is assessing the patient’s functional capacity. This assessment can be accomplished either through a detailed medical history or utilizing a validated assessment tool. The guideline suggests that in most scenarios, individuals demonstrating good functional capacity may proceed with their planned NCS without the necessity for additional testing. However, the definition of good functional capacity may not be rigorous, allowing room for clinician discretion.
Another factor to consider is patient frailty, which tends to increase with advancing age and serves as an important indicator of potential adverse surgical outcomes. It urges careful analysis regarding the risks and benefits of elective surgery and highlights the necessity for heightened perioperative management for patients categorized as frail.
Testing: EKG? Echo? Stress Test? Labs?
For patients with established cardiac disease as well as asymptomatic individuals facing higher-risk surgeries, obtaining a preoperative EKG is deemed “reasonable” for both establishing a preoperative baseline and directing perioperative management. On the contrary, asymptomatic patients set to undergo low-risk surgeries do not require an EKG.
For patients exhibiting new-onset shortness of breath or physical exam findings suggestive of heart failure, an evaluation of left ventricular function, including testing for NT-proBNP, alongside an echocardiogram, is advisable before proceeding with surgery.
The guidelines surrounding preoperative stress testing permit flexibility for clinical judgment. Notably, the guideline assigns a “2b” rating (indicating a weak recommendation) that states, “Patients undergoing elevated-risk NCS with poor or unknown functional capacity and elevated risk for perioperative cardiovascular events based on a validated risk tool may be considered for stress testing,” while also observing, “In select patients suspected of high-risk ischemia based on symptoms or other factors, stress testing can prove beneficial.” Nonetheless, it is acknowledged that “the positive predictive value of an abnormal test is modest, and it is unclear whether an abnormal test offers additional prognostic value beyond standard risk assessment.”
This raises the important question: What actions should be taken? My perspective is that symptomatic patients clearly necessitate further evaluation, while asymptomatic patients show no evident value in undergoing stress testing. This aligns closely with our general approach to stress testing, irrespective of surgical plans.
Postponing a Procedure
Now, let’s examine various specific scenarios. First, addressing hypertension, it is generally advisable to maintain the patient’s regular anti-hypertensive treatment. However, it is crucial to be aware that uncontrolled hypertension has been linked to an increase in perioperative complications. If a patient presents with a blood pressure exceeding 180 systolic or 110 diastolic, elective surgery should potentially be delayed until better blood pressure management is achieved.
In cases where a patient is experiencing decompensated heart failure, the schedule for elective surgery may need to be reconsidered. Further, patients diagnosed with moderate to severe valvular disease — such as aortic stenosis, mitral stenosis, or any type of regurgitation — should undergo thorough evaluation by a cardiologist, which may include an echocardiogram and further interventions depending on the findings of that evaluation. Patients with a prior CVA or TIA should have elective surgery postponed for at least three months after the event.
Perioperative Medication Management
Finally, it is crucial to keep in mind which medications should be paused or adjusted prior to surgery. For instance, SGLT2 inhibitors ought to be withheld for three to four days before surgical procedures. Weekly GLP-1 agonists are also advised to be halted for a minimum of a week prior to elective NCS, while daily GLP-1 agonists should be stopped a full day beforehand, as the risk of delayed gastric emptying may increase the chances of aspiration.
The determination of whether to interrupt antiplatelet therapy for individuals with coronary disease or anticoagulation for patients suffering from atrial fibrillation or venous thromboembolic conditions necessitates a careful weighing of risks and benefits. Should uncertainty arise, it is prudent to consult with the patient’s cardiologist. Generally, bridging with heparin is not recommended upon cessation of oral anticoagulation. Further detailed instruction regarding the timeframe for stopping DOACs or warfarin before surgery can be referenced in the guidelines.
In the realm of primary care, where we frequently conduct preoperative assessments, it is important to recognize that many of these evaluations are oriented towards low-risk surgeries. For patients demonstrating good functional capacity and lacking any cardiac symptoms, the associated surgical risks can be deemed acceptable without need for more extensive cardiac evaluations.
For those presenting with cardiac symptoms, such as chest pain, shortness of breath, or underlying signs of heart failure, it is necessary to decelerate the process and conduct further assessments. In situations of uncertainty, it is entirely appropriate to seek additional clearance from our colleagues in cardiology.
Furthermore, it is vital to note that the guidelines primarily pertain to cardiac risk. Surgical risk encompasses more than just cardiac considerations. For instance, the lungs, particularly in patients with a diagnosis of COPD, must also be monitored. Additionally, consider patients who have received significant amounts of steroids in the past year, as they may require stress-dose steroids during the perioperative period.
How do you approach preoperative evaluation in your practice?
Preoperative Evaluations: The Fun House Mirror of Medicine
Well, well, well. Here we are, back again, diving into the absolute joy that is preoperative evaluations. If you’ve ever thought your job was relatively easy (like a dentist on a Tuesday), wait until you step into the world of American Heart Association guidelines for perioperative cardiovascular management for noncardiac surgery! You know, for those surgeries that don’t *technically* involve the heart but somehow require more checks than a toddler’s playroom after a birthday party.
So let’s break this down, shall we? It’s all about a “stepwise approach” to determine if surgery can proceed—and no, I’m not talking about your dad trying to dance at a wedding. We’ve got high-risk procedures that can have all the glamour of a heart transplant, while low-risk ones are more like a stroll through the park. I mean, you wouldn’t do a pre-op evaluation before getting your wisdom teeth out, would you? (Unless, of course, you want to relive the joyous experience of anesthesia.)
Surgical Procedures and Degree of Risk: The Medical Tinder
You see, surgeons have their own version of Tinder: swiping left on low-risk procedures like cataract surgeries (you know, the ones that don’t require a PhD to understand), and swiping right for the drama of vascular surgeries. The guidelines are clear: the heavier the medical drama, the more scrutiny the patient gets. After all, we wouldn’t want someone going under the knife without a solid functional capacity, which is essentially doctor-speak for “Can you walk up a flight of stairs without having a heart attack?”
And let’s not forget frailty! It’s like a red flag on dating apps: “I might not be able to handle this complication.” The guidelines leave room for clinical judgment—read: it’s totally up to you and your gut feeling. Trust me, doctors have had worse feelings—like after a Saturday night out!
Testing: EKG? Echo? Stress Test? A Pick Your Poison Game!
Now, when it comes to testing, it’s a mixed bag, isn’t it? EKGs for the cardiac folks, and maybe a stress test for asymptomatic patients? Now that’s the medical world trying to get its cardio on! But here’s the kicker: the guidelines are as clear as mud—if you’re symptomatic, cool; more tests are in order. But if not? Well, skip the stress test—not that kind of “I love you but I just can’t” stress, folks.
Postponing a Procedure: The Ultimate Cliffhanger
Oh, and if you think butchering someone’s surgery in a dramatic fashion can only happen on TV, think again! If you have hypertension, hold your horses; if your blood pressure looks like a graph of my love life (higher than 180 systolic), maybe reschedule that elective surgery. Why? Because uncontrolled hypertension could lead to complications—like a butter-fingered surgeon, and nobody wants that!
Perioperative Medication Management: The Juggling Act
Finally, the medication regime—a real circus act where antiplatelet therapy and anticoagulation come into play. It’s like deciding whether to hold the ringmaster or the lion; it’s all about balancing the risks! Before you hit surgery, SGLT2 inhibitors—hold them for 3-4 days. The potential for delayed gastric emptying might as well mean our patients turning into the human version of a popcorn kernel: pressure’s building, and you know the explosion is coming!
So, What’s the Bottom Line?
In conclusion, the bottom line in primary care is this—most low-risk surgeries are just that: low-risk. But for patients who crack under pressure (or have a heart that might do the same), do everyone a favor and request a cardiology consult. Because at the end of the day, while we’re all playing “doctor,” there’s just too much at stake to wing it.
So, how do you approach preoperative evaluations in your own practice? Let’s hope it’s smoother than a bad first date!
Omatic, get those tests rolling; if you’re asymptomatic and facing low-risk surgery, just don’t bother. It’s like picking teams for dodgeball—some get a pass, while others need to step up to the plate.
But what about the patients who develop shortness of breath out of nowhere? Well, my friend, that’s your cue to order some tests to assess left ventricular function and consider an echocardiogram. Because nothing screams “I care” like a little pre-op heart check-up!
Delaying Surgery: When to Hit the Pause Button
Let’s pivot to those moments when you might need to delay a procedure—like when a patient shows up with hypertension that rivals a boiling kettle. If their blood pressure is higher than 180/110, it’s probably time to put the brakes on elective surgery till they get it under control. We don’t need any fireworks during an operation, thank you very much!
And decompensated heart failure? Yeah, that’s a solid sign to rethink your surgical plans. Because if the heart isn’t keeping up, neither should you push them into surgery.
Managing Medications: The Preoperative Juggling Act
Medications? Oh boy! It’s like preparing for a high-stakes game of Jenga. SGLT2 inhibitors need to be paused a few days prior, GLP-1 agonists a week or even a full day before, because delayed gastric emptying is nobody’s friend when you have a scalpel in hand.
Now, anticoagulants and antiplatelet therapy are where the stakes really get high. The decision to interrupt can give you white-knuckle moments. If you’re unsure, pick up the phone and consult with a cardiologist—better to be safe than sorry when matters of the heart are on the line!
Bridging Gaps: This Isn’t a Relationship Blog
Bridging with heparin after halting oral anticoagulation? Generally not recommended, folks. Check guidelines for specifics on DOACs and warfarin and save yourself the headache. And let’s not forget, although we’re talking cardiac risk here, surgical risk is a broader canvas—don’t overlook the lung issues or those steroid-laden patients.
Final Thoughts: The Preoperative Evaluation Sprint
In primary care settings, many of us are tackling preoperative evaluations that often lean towards low-risk surgeries. If patients are functional and symptom-free, it’s generally fine to greenlight the surgery without digging deeper into the heart’s affairs. But when the cardiac symptoms crop up—chest pain, shortness of breath, the works—it’s time to hit the brakes and ensure you have all your ducks in a row before proceeding. Consulting cardiology for extra clearance isn’t just okay—it’s encouraged!
So, how do you approach preoperative evaluation in your practice? Do you tackle it with the precision of a surgeon or just wing it like a karaoke night?
