Cardiovascular Disease: Preoperative Testing and Evaluation for Noncardiac Surgery

Introduction

The overall goal of a preoperative cardiovascular evaluation, and the goal of perioperative medicine in general, is to establish the individual's cardiovascular risk. Mortality from cardiovascular disease has decreased since the 1970s, most likely from a combination of improved pharmacological management, the development of advanced surgical techniques, and the adoption of healthier lifestyles. Nevertheless, more recently, the rates of cardiovascular disease are increasing and again becoming a key cause-of-death affecting life expectancy in the United States (US) and the United Kingdom (UK).

The mean age of our population is increasing, with “baby boomers” now entering their 70s and 80s. Greater numbers of these patients are now presenting for surgery in advanced age, usually with multiple cardiovascular comorbidities, such as chronic hypertension, renal disease, stroke, pulmonary disease, valvopathies, heart failure, previous surgery, and other diseases associated with aging. We list the conditions that pose the greatest risks in Table 55.1 , all of which can have significant implications on surgical risks.

Although overall perioperative mortality is only 0.3%, cardiac etiologies account for up to 50% of these perioperative deaths. Myocardial injury, defined as an elevated troponin greater than the 99th percentile, occurs in up to 20% of patients after noncardiac surgery. Myocardial infarction (MI) is the most common cardiac complication, occurring within 72 hours postoperatively with the peak incidence at 48 hours. Perioperative MIs have atypical presentations and are almost always non-ST elevation MIs (NSTEMIs). Perioperative evaluation and risk assessment, therefore, becomes a critical step toward the reduction of perioperative morbidity and mortality in this population.