Risk Stratification

Question 1

Step 1

Answer 1

Urgency of surgery? Proceed if it is an emergency.

Question 2

Step 2

Answer 2

Unstable cardiac conditions defined by unstable coronary
syndromes, severe arrhythmias, decompensated heart failure
and symptomatic valvular disease; management of patients with
these conditions should be discussed by a multidisciplinary team
weighing the risks and benefits of delaying surgery to optimise
the patient.

Question 3

Step 3

Answer 3

The risk of surgery low risk < 1%,

moderate risk 1–5%,

high risk > 5%.

Question 4

Step 4

Answer 4

Functional capacity METS > 4 – Proceed.

Question 5

Step 4

Answer 5

METS ≤ 4 consider surgical risk if it is low or moderate- proceed

Answer 6

STEP 6: High-risk surgery with METS ≤ 4 used RCRI to evaluate risk
of MACE. Risk factors ≤ 2 consider biomarkers.

Question 7

Step 7

Answer 7

STEP 7: RCRI score ≥ 3 noninvasive stress testing recommended.
Results with evidence of severe ischaemia, coronary
revascularisation should be considered.

Question 8

Methods of preoperative cardiac risk assessment

Answer 8

RCRI- Most validated
NSQIP MICA
ACS NSQIP

Question 9

Advantage of rcri

Question 10

Advantage of NSQIP

Answer 10

Superior discrimination over rcri but may underestimate cardiac risk

Question 11

Disadvantages of NSQIP

Answer 11

No external validation
Underestimate risk

Question 12

Self reported functional capacity

Answer 12

MET

Answer 13

did not predict perioperative cardiovascular
complications (adjusted odds ratio [aOR], 1.81; 95% CI,
0.94-3.46
METs were not inde-
pendently predictive of major perioperative cardiac compli-
cations.

Question 14

Cardiac biomarkers

Answer 14

Brain natriuretic peptides (BNPs) and N-terminal frag-
ment of proBNP (NT-proBNP) are released from the
myocardium in response to various stimuli such as myocardial
stretch and ischemia.

Answer 15

We recommend measuring NT-proBNP or BNP
before noncardiac surgery to enhance perioperative
cardiac risk estimation in patients who are 65 years of
age or older, are 45-64 years of age with significant
cardiovascular disease, or have an RCRI score 1
(Strong Recommendation; Moderate-Quality Evi-
dence).

Answer 16

Values 300 ng/L for NT-proBNP and 92 mg/L
for BNP were identified as significant thresholds associated
with an increased risk of the primary outcome

Answer 17

We recommend against performing preoperative
resting echocardiography to enhance perioperative
cardiac risk estimation (Strong Recommendation; Low-
Quality Evidence).

Answer 18

The prognostic ca-
pabilities of an RCRI threshold 2 increased with the addi-
tion of an NT-proBNP threshold of 301 ng/L (ie, an RR of
1.4; 95% CI, 1.0-1.8 went to an RR of 3.7; 95% CI, 2.7-5.0;
P < 0.001); however, use of echocardiographic parameters in
addition did not result in a further increase in the RR

Answer 19

We recommend against performing preoperative
CCTA to enhance perioperative cardiac risk estimation
(Strong Recommendation; Moderate-Quality
Evidence).

Question 20

VISION
CCTA study setup

Answer 20

This was a pro-
spective cohort study conducted at 12 centres in 8 countries that
evaluated the prognostic capabilities of preoperative CCTA to
enhance perioperative risk prediction beyond clinical data in
955 patients. The CCTA results were blinded unless significant
left main disease was identified, and patients had daily troponin
measurements for 3 days after surgery.22 The primary outcome
of cardiovascular death and nonfatal myocardial infarction
occurred in 74 patients (7.7%) within 30 days of surgery

Answer 21

The study showed, compared with the RCRI alone, that
preoperative CCTA findings improved risk estimation (ie,extensive obstructive disease had an adjusted hazard ratio
[aHR], 3.76; 95% CI, 1.12-12.62) among patients who suffered the primary outcome, but also overestimated risk among patients who did not suffer the primary outcome. Although CCTA findings can appropriately improve risk estimation
among patients who will suffer the primary outcome, CCTA
findings are more than 5 times as likely to lead to an inappropriate overestimation of risk among patients who will not suffer a perioperative cardiovascular death or myocardial infarction.
The overall absolute net reclassification in a sample of 1000
patients is that CCTA will result in an inappropriate estimate of risk in 81 patients (on the basis of risk categories of < 5%, 5%-
15%, and > 15% for the primary outcome).

Answer 22

We recommend against performing preoperative ex-
ercise stress testing to enhance perioperative cardiac
risk estimation (Strong Recommendation; Low-
Quality Evidence).

Answer 23

We recommend against performing preoperative
CPET to enhance perioperative cardiac risk estima-
tion (Strong Recommendation; Low-Quality
Evidence).

Answer 24

12. We recommend against performing preoperative
    pharmacological stress echocardiography to enhance
    perioperative cardiac risk estimation (Strong Recom-
    mendation; Low-Quality Evidence).
13. We recommend against performing preoperative
    pharmacological stress radionuclide imaging to
    enhance perioperative cardiac risk estimation (Strong
    Recommendation; Moderate-Quality Evidence).
    Values and preferences. The panel believed that
    the cost and potential delays associated with these stress
    tests should be taken into account because of the
    absence of evidence of an overall absolute net
    improvement in risk reclassification.

Question 25

Pulmonary Embolism Prevention (PEP)
trial

Answer 25

showed that ASA prevents venous thromboembolism
(HR, 0.64; 95% CI, 0.50-0.81) in patients who undergo hip
fracture surgery.54 In PEP, ASA was associated with an
increased risk of myocardial infarction (HR, 1.33; 95% CI,
1.00-1.78); however, there was no systematic monitoring of
cardiac biomarkers after surgery, and there were only 184
myocardial infarctions.

Question 26

The Perioperative Ischemic Evaluation-2 (POISE-2) trial

Answer 26

large RCT of 10,010 patients who underwent a wide
spectrum of in-hospital noncardiac surgeries.55 Patients who
underwent a carotid endarterectomy, had received a bare-
metal stent in the 6 weeks before surgery, or had received a
drug-eluting stent in the 12 months before surgery were
excluded from the trial. Patients had systematic monitoring of
cardiac biomarkers or enzymes for the first 3 days after surgery.
POISE-2 included 5628 patients who were not
previously taking ASA and 4382 patients who were taking
ASA chronically but had stopped taking it a minimum of 3
days (median of 7 days) before surgery

Answer 27

POISE-2 showed no effect of ASA on myocardial
infarction and cardiac or all-cause mortality. POISE-2, similar
to PEP, showed perioperative ASA increased the risk of major
bleeding.

Answer 28

. We recommend against initiation of ASA for the
prevention of perioperative cardiac events (Strong
Recommendation; High-Quality Evidence).
15. We recommend against the continuation of ASA to
prevent perioperative cardiac events, except in patients
with a recent coronary artery stent and patients who
undergo carotid endarterectomy (Strong Recommen-
dation; High-Quality Evidence

Answer 29

We recommend against b-blocker initiation within 24
hours before noncardiac surgery (Strong Recommen-
dation; High-Quality Evidence)
Among patients taking a b-blocker chronically, we
suggest to continue the b-blocker during the periop-
erative period (Conditional Recommendation;
Low-Quality Evidence

Answer 30

We recommend against preoperative initiation of an
a2-agonist for the prevention of perioperative
cardiovascular events (Strong Recommendation;
High-Quality Evidence

Question 31

Evidence for alpha 2