This document discusses preoperative assessment and cardiac intervention prior to noncardiac surgery. It covers several topics: 1. Perioperative myocardial infarction is common in the first 48-72 hours after surgery due to hemodynamic stresses and alterations that can cause plaque rupture or oxygen supply-demand mismatch. Routine troponin testing detects many clinically silent infarcts. 2. For stable coronary artery disease, preoperative revascularization through PCI or CABG is generally not recommended as studies found no reduction in adverse cardiac events. Indications for preoperative angiography include extensive ischemia on testing or severe angina. 3. For surgery within 12 months of stent placement, the risks of stopping antiplatelet therapy must

1. D R N A J E E B U L L A H S O F I
L P S I N S T I T U T E O F C A R D I O L O G Y
Preoperative assessment and Cardiac
Intervention Prior to Noncardiac Surgery

2. Introduction
 Noncardiac surgery (NCS) is associated with a considerable risk of
adverse cardiac events among individuals with coronary artery or aortic
valve disease.
 It has been noted that if perioperative mortality were categorized as a
unique entity, it would constitute the third leading cause of death in the
United States, with approximately one-third of such fatal complications
related to cardiac events.
 In addition, up to 10% of individuals who undergo coronary stenting
require unanticipated NCS within the subsequent year.

4. Perioperative MI
 In the vast majority of instances, PMI does not occur during the surgical
procedure but rather within the first 48 to 72 hours following surgery.
 This period is associated with multiple hemodynamic stresses and
hematologic alterations that can predispose to plaque rupture,
myocardial oxygen supply-demand mismatch, and a hypercoagulable
state.
 The risk of MI can remain elevated for several weeks following major
surgery.
 The majority of infarcts in the postoperative period are clinically silent
and remain unrecognized unless routine troponin testing is performed.

5.  VISION study of 21,482 patients undergoing NCS, hsTnT testing
detected the occurrence of PMI among 17.9% of participants, of whom
93.1% did not experience ischemic symptoms.
 Routine troponin testing after NCS was associated with a threefold
greater detection rate of PMI compared with testing prompted by
clinical suspicion alone.
 Thirty-day mortality rates following PMI are quite high, in the range of
10%, and even small or clinically silent infarcts are associated with
considerably elevated intermediate- and late-term mortality
independent of other clinical factors.

6. Assessment of Risk
 Preoperative clinical evaluation of patients may identify stable or unstable
CAD.
 Multiple studies have demonstrated an increased incidence of reinfarction after
noncardiac surgery if the previous MI had occurred within 6 months of the
operation. Improvements in MI management and perioperative care have
shortened this interval.
 The AHA/ACC Task Force has suggested that the highest-risk patients are
those within 30 days of MI, during which time plaque and myocardial healing
occur. After this period, risk stratification is based on the features of the disease
(i.e., those with active ischemia are at highest risk).
CAD

7. Stable CAD
 Two randomized trials have examined the role of coronary revascularization as a means
to reduce the likelihood of perioperative events among individuals with stable coronary
artery disease (CAD) scheduled to undergo vascular surgery.
 The Coronary Artery Revascularization Prophylaxis (CARP) trial compared the strategy
of preoperative coronary revascularization with that of stand-alone medical therapy for
the reduction of early and late cardiac events following major vascular surgery.
 510 patients scheduled for vascular surgery at one of 18 Veterans Affairs (VA) Medical
Centers. Patients were eligible if angiography-proven CAD with a 70% or more stenosis
in at least one major epicardial coronary artery was present, and they were randomized
to either coronary revascularization followed by vascular surgery or to vascular surgery
without preceding coronary revascularization. Among the group randomized to coronary
revascularization, 41% of patients underwent coronary artery bypass grafting
(CABG), and 59% were treated with PCI.

8.  The majority of patients enrolled in the CARP trial were at low to intermediate rather than high
risk for perioperative coronary events.
 The median age was 66 years, and whereas 42% had a prior MI, only 38% noted the presence of
angina at the time of study entry, and less than 50% underwent a stress imaging study that
documented moderate or severe ischemia prior to coronary angiography. Most patients had one- or
two-vessel coronary disease with preserved left ventricular (LV) function, and those with left main
stenosis of 50% or greater, a left ventricular ejection fraction (LVEF) of less than 20%, or severe aortic
stenosis (AS) were excluded.
 The results of the CARP trial indicated that preoperative
revascularization was not associated with any apparent benefit over
conservative therapy. Although patients assigned to coronary revascularization had a
significantly longer delay between randomization and vascular surgery (54 vs. 18 days), neither
preoperative PCI nor CABG was associated with a reduction in the occurrence of adverse cardiac
events or overall survival following vascular surgery at 30-day or 2.7-year follow-up

9.  The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
(DECREASE-V) pilot study was designed to evaluate the effectiveness of prophylactic
coronary revascularization prior to major vascular surgery among a higher-risk group of
patients than those enrolled in the CARP trial.
 A total of 101 patients with extensive myocardial ischemia on noninvasive stress imaging
were randomized to either revascularization (65% had PCI, 35% had CABG) or no
revascularization prior to vascular surgery.
 Within this small cohort, preoperative coronary revascularization was not associated
with significant differences in the occurrence of death or MI either at 30 days or 1
year following NCS.
 Thus, despite their potential shortcomings, the CARP and DECREASE-V
results lend support to the concept that performing prophylactic coronary
revascularization in the setting of stable CAD for the purpose of “getting
a patient through” NCS is rarely appropriate.

10. Indications for Preoperative Coronary Angiography
 Despite the frequency and adverse implications of PMI, evidence that prophylactic
coronary angiography and/or revascularization can mitigate the risk of perioperative
cardiac events is lacking.
 ACC/AHA consensus guidelines assert that preoperative coronary revascularization
is “appropriate for only a small subset of patients at very high risk” and should be
used sparingly if at all.
 Based primarily on expert opinion, specific instances when preoperative coronary
angiography should be considered include:
1. Noninvasive test results suggesting a high risk of adverse outcomes, such as extensive (multivessel
distribution) MI, prior to high-risk surgery.
2. Canadian Cardiovascular Society (CCS) class III or IV angina not responsive to appropriate medical
therapy.
3. Recent acute coronary syndrome or MI.
4. Moderate or severe aortic valve stenosis and anginal symptoms or heart failure.

13. Revascularization Technique
 When the decision has been made to perform preoperative PCI, a foremost
consideration is the urgency of the surgical procedure, which often dictates
whether stand-alone balloon angioplasty, bare-metal stenting (BMS), or drug-
eluting stent (DES) implantation is performed.

14.  Current ACC/AHA guidelines recommend delaying surgery for at least 2
weeks following balloon angioplasty to allow for initial healing at the
site of vessel injury and to overcome the usual time frame during which
acute vessel closure and recoil typically occur. Surgery should not be
delayed for more than 8 to 12 weeks following angioplasty because
restenosis becomes a potential concern after this interval.
 Elective NCS be postponed when possible for at least 12 months
following first-generation DES placement. The likelihood of stent
thrombosis with newer-generation DESs appears similar to that with
BMSs, and shorter dual antiplatelet therapy (DAPT) durations have
become safe

16. NCS after CABG
 Attempting to perform NCS very shortly after CABG may be associated
with increased operative risks.
 For example, patients undergoing vascular surgery within 1 month of
CABG in one observational study demonstrated a fivefold increase in
operative mortality compared with matched controls who underwent
vascular surgery without preceding CABG (20.6 vs. 3.9%, P < .005).
 In a review of 211 patients who underwent NCS within 1 year of
CABG, significant risk factors for adverse events included ejection
fraction less than 45% and pulmonary artery systolic pressure greater
than 40 mm Hg, and approximately two-third of adverse events
occurred when NCS was performed within 90 days of CABG.

17. Unanticipated Surgery after Stenting
 Approximately 5% to 10% of patients who undergo PCI will require an
unanticipated surgical procedure during the first year after stent placement.
 For these individuals, the decision whether to continue or suspend antiplatelet
therapy during NCS involves a presumptive trade-off between perioperative
ischemic events and bleeding complications.
 The likelihood of ischemic events including those related to stent thrombosis is
especially high if surgery is performed within the first 4 to 6 weeks following
either BMS or DES placement. After 6 weeks, perioperative cardiac event rates
fall substantially and appear to reach a stable nadir at 6 to 12 months after
stent placement

19.  In a Scottish registry Mortality rates fell after 6 weeks but remained fourfold
greater when surgery was performed between 42 days and 1 year
compared with after 1 year post PCI.
 In a retrospective analysis of nearly 25,000 NCS procedures performed at
Mayo Clinic, previous stent placement was associated with a greater than
twofold increase in MACE and bleeding events when NCS was performed
within 1 year of PCI, but the risk was not elevated after 1 year.
 Notably, no association was noted between stent type (BMS vs. DES) and
adverse events.

20. Antiplatelet Drug Interruption
 In a registry of 4896 patients who received a zotarolimus-eluting stent, DAPT interruption
within the first month was associated with a substantial rate of definite or probable stent
thrombosis (3.6%) and cardiac death or target-vessel MI (6.8%); however, interruption
after 1 month was not associated with an increased risk of stent thrombosis or
MACE.
 Likewise, in a pooled analysis of 11,219 patients enrolled in seven trials or registries of
everolimus-eluting stent implantation, DAPT discontinuation before 30 days was strongly
associated with the occurrence of stent thrombosis; however, after 90 days there was
no association between DAPT interruption and stent thrombosis.
 (PARIS) registry, 10.5% of patients had interruption of at least one antiplatelet drug
(aspirin and/or a P2Y12 receptor blocker) prior to a surgical procedure within 2 years of
stent placement.76 A nonsignificant trend toward increased MACE was observed among
patients with DAPT interruption for surgery compared with the overall cohort (hazard ratio
[HR], 1.41; 95% confidence interval [CI], 0.94 to 2.12; P = .10)

21.  Among a separate cohort of 1134 consecutive patients with coronary stents
who underwent NCS at one of 47 French centers, 10.4% suffered a
postoperative major adverse cardiac or cerebrovascular event, and such
events were independently associated with cessation of antiplatelet therapy 5
or more days prior to surgery.
 Conversely, in a Japanese registry of 2398 patients who underwent surgery
within 3 years of coronary BMS or DES placement, continuation of DAPT
during surgery was associated with neither a decrease in the rates of
perioperative death, MI, or stent thrombosis nor an increase in bleeding events.
 Although uncommon, it should be noted that very late stent thrombosis
has been observed following cessation of DAPT for NCS months to years
following second-generation DES placement.

23. Summary and Recommendations

24.  All societal guideline statements
strongly urge that aspirin be
continued whenever possible
following stenting if
P2Y12 inhibitor therapy is
stopped for NCS.
 It should be determined whether the
patient possesses any additional risk
factors such as recent MI, renal
insufficiency, DM , or stent use in
complex coronary anatomy including
long segment, overlapping, small
vessel, or bifurcation stenting, all of
which have been associated with an
increased propensity for stent
thrombosis.If such risk factors exist,
delaying elective NCS for at least 6
months may be prudent.
 For operations that have low
bleeding risk, DAPT should be
continued through surgery
whenever possible.
 If bleeding risk is moderate,
preoperative cessation of
P2Y12 inhibitor therapy with
continuation of aspirin is typically
recommended.
 For surgical procedures that
involve closed spaces or those
associated with a high risk of
substantial blood loss,
temporary cessation of all
antiplatelet therapy is often
compulsory.

25. Perioperative bridging
 For highly selected patients at particularly high risk of both perioperative
stent thrombosis and surgical bleeding: A strategy of perioperative
bridging can be considered.
 When the decision is made to discontinue P2Y12 receptor–antagonist therapy
for NCS, pharmacokinetic data suggest that clopidogrel and ticagrelor be
stopped 5 days and prasugrel 7 days before the operation, to allow adequate
time for recovery of platelet function.

26. HF
Hypertension
 The 30-day postoperative mortality
rate was significantly higher in
patients with both nonischemic
(9.3%) and ischemic (9.2%) HF
compared to those with CAD
(2.9%) in a population-based data
analysis of 38,047 consecutive
patients
 BP excursions in the operative and
postoperative period portend
worsening outcome.
 A hypertensive crisis in the
postoperative period—defined as
diastolic BP higher than 120 mm
Hg and clinical evidence of
impending or actual end-organ
damage—poses a definite risk for
MI and cerebrovascular accident
(CVA, stroke).

27. Valvular Heart Disease
 The presence of symptomatic severe
AS remains an important risk factor for
adverse events with NCS.
 Symptomatic status appears to
represent a key factor in determining
the risk for adverse perioperative
events among patients with severe AS
who undergo NCS.
 In a case-control study of 256 patients with
severe AS undergoing NCS, asymptomatic
patients were not at increased risk for 30-
day MACE or mortality compared with
matched controls, whereas the presence of
symptoms (angina, dyspnea, or syncope)
was associated with significantly elevated
30-day MACE and 1-year mortality rates.
 A meta-analysis of three case-control studies
examining patients with severe asymptomatic
AS who underwent a moderate or high-risk
noncardiac surgical procedure likewise
indicated that the presence of severe
asymptomatic AS was not associated with a
significant increase in 30-day MACE.
 Similarly, among 634 patients with moderate
or severe AS who underwent NCS at the
Cleveland Clinic, significant predictors of
adverse outcomes included symptomatic
severe AS, high-risk surgery, and coexistent
mitral regurgitation or CAD.

28.  When surgery is considered urgent, such that
there is insufficient time to prepare for,
perform, or allow recovery from SAVR or
TAVR, BAV represents a tenable option for
patients with severe symptomatic AS.
 BAV typically results in a modest
improvement in aortic valve area, rarely to
greater than 1.0 cm2, which nevertheless
may be sufficient to reduce the impact of
hemodynamic stresses inherent to higher-risk
NCS.
 BAV represents a temporizing measure,
because restenosis of the aortic valve with
return of clinical symptoms and severe
stenosis is nearly universal at 6 to 12 months
post procedure

29. 2014 ACC/AHA Guideline on
Perioperative Cardiovascular
Evaluation and Management of
Patients Undergoing
Noncardiac Surgery
Developed in Collaboration With the American College of Surgeons, American
Society of Anesthesiologists, American Society of Echocardiography, American
Society of Nuclear Cardiology, Society for Cardiovascular Angiography and
Interventions, and Society of Cardiovascular Anesthesiologists
© American College of Cardiology Foundation and American Heart Association

30. Stepwise Approach to Perioperative Cardiac Assessment for CAD
Continued on the next slide.

31. Stepwise Approach to Perioperative Cardiac Assessment for CAD (cont’d)
Continued on the next slide.

32. Stepwise Approach to Perioperative Cardiac Assessment for CAD (cont’d)

33. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Supplemental Preoperative Evaluation

34. Supplemental Preoperative Evaluation
Noninvasive Pharmacological Stress Testing
Before Noncardiac Surgery
Recommendations
It is reasonable for patients who are at an elevated risk for
noncardiac surgery and have poor functional capacity (<4
METs) to undergo noninvasive pharmacological stress
testing (either DSE or pharmacological stress MPI) if it will
change management.
Routine screening with noninvasive stress testing is not
useful for patients undergoing low-risk noncardiac surgery.
COR LOE
IIa B
III: No
B
Benefit

35. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Perioperative Therapy

36. Perioperative Therapy
Coronary Revascularization Prior to Noncardiac
Surgery
Recommendations
Revascularization before noncardiac surgery is
recommended in circumstances in which revascularization
is indicated according to existing CPGs.
It is not recommended that routine coronary
revascularization be performed before noncardiac surgery
COR LOE
I C
III: No
exclusively to reduce perioperative cardiac events. Benefit
B

37. Perioperative Therapy
Timing of Elective Noncardiac Surgery in Patients With
Previous PCI
Recommendations
Elective noncardiac surgery should be delayed 14 days
after balloon angioplasty…
…and 30 days after BMS implantation
Elective noncardiac surgery should optimally be delayed
365 days after DES implantation.
In patients in whom noncardiac surgery is required, a
consensus decision among treating clinicians as to the
relative risks of surgery and discontinuation or continuation
of antiplatelet therapy can be useful.
COR LOE
I C
I B
I B
IIa C

38. Perioperative Therapy
Timing of Elective Noncardiac Surgery in Patients With
Previous PCI (cont’d)
Recommendations
Elective noncardiac surgery after DES implantation may be
considered after 180 days if the risk of further delay is
greater than the expected risks of ischemia and stent
thrombosis.
Elective noncardiac surgery should not be performed within
30 days after BMS implantation or within 12 months after
COR LOE
IIb* B
III:
DES implantation in patients in whom DAPT will need to be
discontinued perioperatively.
Elective noncardiac surgery should not be performed within
14 days of balloon angioplasty in patients in whom aspirin
will need to be discontinued perioperatively.
Harm
III:
Harm
B
C
*Because of new evidence, this is a new recommendation since the publication of the 2011
PCI CPG

39. Perioperative Therapy
Perioperative Beta-Blocker Therapy
Recommendations
Beta blockers should be continued in patients undergoing
surgery who have been on beta blockers chronically.
It is reasonable for the management of beta blockers after
surgery to be guided by clinical circumstances, independent of
when the agent was started.
In patients with intermediate- or high-risk myocardial ischemia
noted in preoperative risk stratification tests, it may be
reasonable to begin perioperative beta blockers.
In patients with 3 or more RCRI risk factors (e.g., diabetes
mellitus, HF, CAD, renal insufficiency, cerebrovascular
accident), it may be reasonable to begin beta blockers before
surgery.
COR LOE
I BSR
IIa BSR
IIb CSR
IIb BSR
These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s
systematic review. See the ERC systematic review report, “Perioperative beta blockade in noncardiac surgery: a
systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of
patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.

40. Perioperative Therapy
Perioperative Beta-Blocker Therapy (cont’d)
Recommendations
In patients with a compelling long-term indication for beta-
blocker therapy but no other RCRI risk factors, initiating
COR LOE
BSR
beta blockers in the perioperative setting as an approach to
reduce perioperative risk is of uncertain benefit.
In patients in whom beta-blocker therapy is initiated, it may
be reasonable to begin perioperative beta blockers long
enough in advance to assess safety and tolerability,
preferably more than 1 day before surgery.
Beta-blocker therapy should not be started on the day of
surgery.
IIb
IIb
III:
Harm
BSR
BSR
These recommendations have been designated with a SR to emphasize the rigor of support from the ERC’s
systematic review. See the ERC systematic review report, “Perioperative beta blockade in noncardiac surgery: a
systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of
patients undergoing noncardiac surgery” for the complete evidence review on perioperative beta-blocker therapy.

41. Perioperative Therapy
Antiplatelet Agents
Recommendations
In patients undergoing urgent noncardiac surgery during the
first 4 to 6 weeks after BMS or DES implantation, DAPT
should be continued unless the relative risk of bleeding
outweighs the benefit of the prevention of stent thrombosis.
In patients who have received coronary stents and must undergo surgical
procedures that mandate the discontinuation of P2Y12 platelet receptor-
inhibitor therapy, it is recommended that aspirin be continued if
possible and the P2Y12 platelet receptor-inhibitor be restarted as soon as
possible after surgery.
Management of the perioperative antiplatelet therapy should be
determined by a consensus of the surgeon, anesthesiologist,
cardiologist, and patient, who should weigh the relative risk of
bleeding versus prevention of stent thrombosis.
COR LOE
I C
I C
I C

42. Perioperative Therapy
Antiplatelet Agents (cont’d)
Recommendations
In patients undergoing nonemergency/nonurgent
noncardiac surgery who have not had previous coronary
stenting, it may be reasonable to continue aspirin when the
risk of potential increased cardiac events outweighs the risk
of increased bleeding.
Initiation or continuation of aspirin is not beneficial in
patients undergoing elective noncardiac noncarotid surgery
who have not had previous coronary stenting,…
…unless the risk of ischemic events outweighs the risk
of surgical bleeding.
COR LOE
IIb B
B
III: No
Benefit
C

43. Proposed Algorithm for Antiplatelet Management in Patients
with PCI and Noncardiac Surgery
.
*Assuming patient
is currently on
DAPT.

44. Proposed Algorithm for Antiplatelet Management in Patients
with PCI and Noncardiac Surgery (cont’d)
*Assuming patient
is currently on
DAPT.

45. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Clinical Risk Factors

46. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Calculation of Risk to Predict Perioperative
Cardiac Morbidity

47. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Anesthetic Consideration and Intraoperative
Management

48. Guideline on Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac Surgery
Perioperative Surveillance

49. Perioperative Surveillance
Surveillance and Management for Perioperative MI
Recommendations
Measurement of troponin levels is recommended in the
setting of signs or symptoms suggestive of myocardial
ischemia or MI.
Obtaining an ECG is recommended in the setting of signs
or symptoms suggestive of myocardial ischemia, MI, or
arrhythmia.
The usefulness of postoperative screening with troponin
levels in patients at high risk for perioperative MI, but
without signs or symptoms suggestive of myocardial
ischemia or MI, is uncertain in the absence of established
risks and benefits of a defined management strategy.
COR LOE
I A
I B
IIb B

50. Perioperative Surveillance
Surveillance and Management for Perioperative MI (cont’d)
Recommendations
The usefulness of postoperative screening with ECGs in
patients at high risk for perioperative MI, but without signs
or symptoms suggestive of myocardial ischemia, MI, or
arrhythmia, is uncertain in the absence of established risks
and benefits of a defined management strategy.
Routine postoperative screening with troponin levels in
COR LOE
IIb B
unselected patients without signs or symptoms suggestive III: No
of myocardial ischemia or MI is not useful for guiding Benefit
perioperative management.
B