Cardiac risk assessment prior to non-cardiac surgery resident survival guide

# Overview
Cardiac complications are potential risks of non-cardiac surgeries and interventions. Non-cardiac surgery is associated with a 7% to 11%  overall complication rate, approximately half of which are cardiac in nature. The risk of peri-operative complications is dependent on both the patient's co-morbidities and the type of surgery/intervention. The goal of pre-operative cardiac assessment is to identify patients with ischemic heart diseases, valvulopathies, left ventricular dysfunction, or arrhythmias, all of which might are associated with hemodynamic instability and cardiac stress and may affect the metabolic supply-demand balance during and following the surgery.

# Algorithm for Cardiac Risk Evaluation and Perioperative Management
Shown below is an algorithm summarizing the Cardiac Risk Evaluation and Perioperative Management of according the the 2014 European Society of Cardiology (ESC) / European Society of Anesthesiology (ESA) guidelines.
Abbreviations: MI: Myocardial infarction; BP: Blood Pressure, VT:
Ventricular tachycardia; HF: Heart failure;  AV:  Atrioventricular; ECG: Electrocardiogram; CV: Cardiovascular; CEA: Carotid endarterectomy; CAS: Carotid artery stenting; DAPT: Dual antiplatelet therapy; MET: Metabolic equivalent;  ACEI:  Angiotensin converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; SBP: Systolic blood pressure; NT-proBNP: N-terminal of the prohormone brain natriuretic peptide; BMS: Bare metal stent;  DES:  Drug eluting stent

# Do's
- Perform pre-operative risk assessment independently of an open or laparoscopic surgical approach
- Use clinical risk indices for peri-operative risk stratification
- Use either National Surgical Quality Improvement Program (NSQIP) or Lee risk index for cardiac pre-operative risk stratification
- Perform pre-operative ECG for patients who have risk factor(s) and are scheduled for intermediate or high-risk surgery
- Perform imaging stress testing before high-risk surgery among patients with more than 2 clinical risk factors and poor functional capacity (<4 METs)
- Assess the indications for pre-operative coronary angiography  based on those for non-surgical setting
- Perform urgent angiography among patients with acute ST-segment elevation myocardial infarction (STEMI) requiring non-urgent, non-cardiac surgery
- Perform urgent early invasive strategy among patients with NSTE-ACS who require non-urgent, non-cardiac surgery according to risk assessment
- Perform pre-operative angiography among patients with proven myocardial ischemia and unstabilized chest pain with adequate medical therapy requiring non-urgent, non-cardiac surgery
- Continue beta-blocker therapy among patients currently receiving beta-blockers
- Continue peri-operative statin therapy using long half-life or extended-release formulations
- Continue aspirin therapy for 4 weeks after BMS implantation unless the risk of life-threatening surgical bleeding on aspirin is unacceptably high
- Send asymptomatic non-high risk patients who have undergone CABG in the past 6 years to non-urgent, non-cardiac surgery without angiographic evaluation
- Perform myocardial revascularization according to the applicable guidelines for management in stable CAD
- Consider late revascularization after successful non-cardiac surgery among patients with stable CAD
- Diagnose and treat NSTE-ACS if non-cardiac surgery can be postponed
- Manage NSTE-ACS aggressively among patients who have undergone non-cardiac surgery
- Use either new-generation DES, BMS, or even balloon angioplasty if PCI is indicated before semi-urgent surgery

# Don'ts
- Don't routinely use pre-operative biomarker sampling for risk stratification
- Don't perform routine pre-operative ECG for patients who have no risk factors and are scheduled for low-risk surgery
- Don't perform routine echocardiography among patients undergoing intermediate- or low-risk surgery
- Don't perform imaging stress testing before low-risk surgery regardless of the patient's clinical risk
- Don't perform pre-operative angiography among cardiac stable patients undergoing low-risk surgery
- Don't initiate per-operative high dose beta-blockers without titration
- Don't initiate beta-blockers among patients scheduled for low-risk surgery
- Don't perform prophylactic myocardial revascularization before low- and intermediate-risk surgery among patients with proven ischemic heart disease