Risk Stratification Flashcards
Step 1
Urgency of surgery? Proceed if it is an emergency.
Step 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.
Step 3
The risk of surgery low risk < 1%,
moderate risk 1–5%,
high risk > 5%.
Step 4
Functional capacity METS > 4 – Proceed.
Step 4
METS ≤ 4 consider surgical risk if it is low or moderate- proceed
STEP 6: High-risk surgery with METS ≤ 4 used RCRI to evaluate risk
of MACE. Risk factors ≤ 2 consider biomarkers.
Step 7
STEP 7: RCRI score ≥ 3 noninvasive stress testing recommended.
Results with evidence of severe ischaemia, coronary
revascularisation should be considered.
Methods of preoperative cardiac risk assessment
RCRI- Most validated
NSQIP MICA
ACS NSQIP
Advantage of rcri
Advantage of NSQIP
Superior discrimination over rcri but may underestimate cardiac risk
Disadvantages of NSQIP
No external validation
Underestimate risk
Self reported functional capacity
MET
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.
Cardiac biomarkers
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.
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).
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
We recommend against performing preoperative
resting echocardiography to enhance perioperative
cardiac risk estimation (Strong Recommendation; Low-
Quality Evidence).
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
We recommend against performing preoperative
CCTA to enhance perioperative cardiac risk estimation
(Strong Recommendation; Moderate-Quality
Evidence).
VISION
CCTA study setup
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
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).
We recommend against performing preoperative ex-
ercise stress testing to enhance perioperative cardiac
risk estimation (Strong Recommendation; Low-
Quality Evidence).
We recommend against performing preoperative
CPET to enhance perioperative cardiac risk estima-
tion (Strong Recommendation; Low-Quality
Evidence).
- We recommend against performing preoperative
pharmacological stress echocardiography to enhance
perioperative cardiac risk estimation (Strong Recom-
mendation; Low-Quality Evidence). - 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.
Pulmonary Embolism Prevention (PEP)
trial
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.
The Perioperative Ischemic Evaluation-2 (POISE-2) trial
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
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.
. 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
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
We recommend against preoperative initiation of an
a2-agonist for the prevention of perioperative
cardiovascular events (Strong Recommendation;
High-Quality Evidence
Evidence for alpha 2
