Evaluation of Patients for Noncardiac Surgery

Patient evaluation should be the same in the preoperative setting as in any other setting. To date, no tests or interventions have been shown to be of benefit to patients in the preoperative setting that are not likewise of benefit to patients in the nonpreoperative setting. For this reason, guidelines suggest that the clinical evaluation and testing for patients in the preoperative setting conform to that which would be pursued in the nonpreoperative setting. Noninvasive testing should be pursued selectively. Following bayesian logic, noninvasive testing, like all medical tests, will be of most use, and provide the most information, for patients at indeterminate or intermediate risk. Those patients at highest clinical risk and lowest clinical risk are unlikely to have their status or treatment changed by noninvasive testing. Perioperative beta-blocker therapy improves outcomes in high-risk patients. Studies to date suggest that patients at high clinical risk, or having abnormal noninvasive testing, will benefit from perioperative beta-blockade. The role for beta-blocker therapy during surgery for low risk patients is less clear. Prior coronary revascularization in the recent past is associated with low perioperative cardiac risk during noncardiac surgery. Numerous studies suggest that patients who have undergone coronary artery bypass grafting or percutaneous coronary revascularization, and are without symptoms of active coronary artery disease, have a very low risk of perioperative cardiac events. Data suggest that this benefit extends up to 5 years after coronary artery bypass surgery. Preoperative evaluation offers a unique opportunity to improve modifiable cardiac risk factors. Cardiovascular disease and its complications are the leading cause of death in the developed world. Even patients at low risk for perioperative cardiac complications still face the significant likelihood of eventually developing, and dying from, cardiovascular disease. It is important to exploit the opportunity to address the modifiable risk factors. Surgical treatment of valvular disease carries the same indications prior to noncardiac surgery. Patients presenting for evaluation prior to noncardiac surgery should undergo aortic or mitral valve surgery only if the valve surgery is indicated according to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for treatment of valvular disease. Percutaneous coronary revascularization should be pursued in accordance with the AHA/ACC guidelines. Current data suggest no reduction in perioperative mortality by the pursuit of preoperative coronary revascularization for that reason. Therefore, the mere presence of coronary lesions does not indicate percutaneous revascularization. Revascularization should be pursued for longterm benefit, according to the ACC/AHA guidelines, as for any other patient. Patient functional capacity is important to determine perioperative risk. Patient exercise tolerance affects risk for perioperative events significantly. A clinical assessment of each patient’s exercise capacity informs the determination of the presence of angina, and also directly relates to the patient’s perioperative risk.