Myocardial infarction and cardiac arrest are the 2 most important perioperative complications directly linked to increased mortality. Arrhythmias, unstable angina, and heart failure are additional cardiac complications which can occur during the perioperative period (Papadakis et al., 2022; McPhee et al, 2022).
End-organ cardiovascular disease is the most compelling risk factor for cardiac complications in the perioperative setting. Examples of end-organ cardiovascular disease includes cerebrovascular disease, chronic kidney disease, coronary artery disease, and heart failure. Insulin dependent diabetes is considered a cardiovascular disease equivalent. An elevated serum creatinine level greater than 2 mg/dL is considered a risk factor for cardiovascular complications as well (McPhee et al., 2022).
Certain surgical procedures increase the risk of cardiac complications such as vascular procedures including intrathoracic or intra-abdominal vascular procedures. Several risk factors have been identified and are outlined in the revised cardiac risk index (RCRI).
The number of predictors present correspond to a certain risk percentage (McPhee et al., 2022):
- None: 0.4%
- One: 1%
- Two: 2.4%
- More than two: 5.4%
Patients with limited exercise capacity have increased cardiovascular risk in the perioperative setting. Emergency procedures should not be delayed to perform an extensive cardiovascular assessment.
Most patients with cardiovascular risk factors can be correctly stratified based on their clinical history and physical exam. In patients with at least one revised cardiovascular risk index predictor prior to a major surgical procedure, these patients should have a preoperative electrocardiogram (ECG). Typically, patients scheduled for minor procedures do not need to undergo preoperative cardiovascular screening or testing.
Cardiovascular stress testing is usually reserved for patients with elevated cardiovascular risk scores. Inducible ischemia indicates a high risk of cardiac complications especially when related to vascular procedures. Preoperative B-type natriuretic peptide (BNP) or N-terminal fragment of proBNP correlate with an increased risk of perioperative cardiac complications. A BNP value greater than 92 mg/L or proBNP value greater than or equal to 300 ng/L in the preoperative setting is associated with a 4X increase in 30-day mortality and myocardial infarction (McPhee et al, 2022).
Preoperative medications such as nitrates, beta blockers, or calcium channel blockers should be continued in the perioperative period. The initiation of beta-blockers prior to major cardiovascular procedures have been associated with reduced risk of nonfatal myocardial infarction. On the other hand, the use of a high fixed dose of beta-blockers increased the risk of total mortality and stroke. As such beta-blockers should be started well ahead of the scheduled surgery.