Bottom line: For patients who are unable to complete 4 METs (metabolic equivalents), further cardiac risk stratification includes assessment of the following clinical risk factors: 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/dL. With this information the clinician can provide the patient an estimate of their risk of having a cardiac event in the perioperative period, and decide whether or not to pursue further risk stratification testing.
Use of beta blockers in the perioperative setting (in patients not already taking them and without other indications for them, e.g. HTN (hypertension), s/p (status post) MI (myocardial infarction) for perioperative cardiac risk reduction remains controversial. If beta blocker use is considered for risk reduction in high-risk patients (RCRI (revised cardiac risk index) >2), they should be started well before surgery (weeks) and titrated for HR (heart rate) control and to avoid hypotension.
Summary: DynaMed Plus entry for perioperative cardiac management for noncardiac surgery; references:
ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Aside from evaluating and treating patients with known, active cardiac conditions, patients should be risk-stratified according to the type of surgery and clinical risk factors. Clinical risk factors include history of ischemic heart disease, history of compensated or prior heart failure, history of cerebrovascular disease, diabetes mellitus, and renal insufficiency.
These recommendations are based on Lee TH, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9.
METHODS: 4315 patients age ≥ 50 years undergoing elective major noncardiac surgery in a tertiary-care teaching hospital were evaluated for major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. RESULTS: Independent predictors of complications were identified and included in a Revised Cardiac Risk Index: 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/dL.
Rates of major cardiac complication:
None of the risk factors: 0.5% in derivation cohort and 0.4% in validation cohort
1 risk factor: 1.3% in derivation cohort and 0.9% in validation cohort
2 risk factors: 4% in derivation cohort and 7% in validation cohort
≥ 3 risk factors: 9% in derivation cohort and 11% in validation cohort
POISE Study Group, Devereaux PJ, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May 31;371(9627):1839-47.
RCT of 9,298 high-risk patients (cariovascular disease or any 3 of these 7: having intrathoracic or intraperitoneal surgery, history of heart failure, history of TIA, diabetes, serum creatinine > 1.97 mg/dL, age > 70 years, or having emergent or urgent surgery. Randomized to perioperative metoprolol vs. placebo. RESULTS: Death occurred in 3.1% in metoprolol group vs. 2.3% in placebo group (p = 0.0317, NNH 125). Myocardial infarction occurred in 4.2% in metoprolol group vs. 5.7% in placebo group (p = 0.0017, NNT 67). Nonfatal myocardial infarction occurred in 3.6% in metoprolol group vs. 5.1% in placebo group (p = 0.0008, NNT 67). Clinically significant hypotension occurred in 15% in metoprolol group vs. 9.7% in placebo group (p < 0.0001, NNH 18) and clinically significant bradycardia occurred in 6.6% for metoprolol group vs. 2.4% for placebo group (p < 0.0001, NNH 23).
Full discussion of this trial is in DynaMed Plus entry for “Perioperative cardiac management for noncardiac surgery.”
updated in 2016 ldt