Edited Cardiovascular Evaluation in Patients Undergo Non-Cardiac Surgery - Gadis Virza - Dr. Nur Haryono

Cardiovascular Evaluation in Patients
Undergo Non-Cardiac Surgery
Gadistya Novitri A.
Praditya Virza R.
Resource Person: dr. Nur Haryono, SpJP (K)

Introduction
Cardiovascular management of patients in whom heart disease is a potential source
of complications during non-cardiac surgery. More specifically in patients with IHD,
VHD, Left Ventricular dysfunction and arrhythmias
Non-cardiac surgery is associated with an overall complication rate of 7–11%,

mortality rate of 0.8- 1.5%.
42% of these are caused by cardiac complications.
Risk of perioperative complications depends on the condition of the patient before

surgery, comorbidities, the urgency, magnitude, type, and duration of the surgical
procedure
Demographics of patients undergoing surgery show a trend towards an increasing

number of elderly patients and comorbidities (cardiovascular disease is the most
prevalent)
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. European Heart Journal (2014) 35, 2383–
2431
Pathophysiology
Surgical procedure will produce stress response
This response is initiated by tissue injury and mediated by

neuro-endocrine factors, induce sympathovagal imbalance.
Increases myocardial oxygen demand
Alterations in the balance between prothrombotic and

fibrinolytic factors
Increased coronary thrombogenicity
Haemodynamic derangements, leading to myocardial

ischaemia and heart failure
Perioperative Management to Reduce Cardiovascular Events. Circulation. 2016;133:1125–1130

2431
Risk Factor
Patient-related risk factors Procedure-related factors
• Ischemic heart disease • Urgency
• Hypertension • Invasiveness
• Heart failure • Duration of the procedure
• Cardiomyopathy • Change in body core temperature
• Valvular heart disease • Blood loss
• Congenital heart disease in adults • Fluid shifts
• Arrhytmias
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the Ame
rican College of Cardiology/American Heart Association Task Force on Practice Guidelines
Risk Factor
Surgery related
1 Emergency procedure : one in which life or limb is threatened if not in the operating room. There
is time for no or very limited or minimal clinical evaluation, typically within <6 hours.
2 An urgent procedure : there maybe time for a limited clinical evaluation, usually when life
or limb is threatened if not in the operating room, typically between 6 and 24 hours
A time-sensitive procedure: a delay of >1 to 6 weeks to allow for an evaluation and

3 significant changes in management will negatively affect outcome
4 An elective procedure is one in which the procedure could be delayed for up to 1 year.
. J Am Coll Cardiol. 2014 Dec, 64 (22) e77–e137
Ischemic heart disease
• Stress related to noncardiac surgery increases metabolic requirements and
activates the sympathetic nervous system raise the heart rate preoperatively
 high incidence of symptomatic and asymptomatic myocardial ischemia
• Preoperative clinical evaluation: stable or unstable
Risk factor :
• length of time from MI to operation : length of time >>> postoperative MI rate

dan mortality rate <<<
• presence and type of coronary revascularization when MI occurred (CABG or
PCI)
• Patients age: >65 years of age have higher incidence of acute ischemic stroke
Evaluation in patient with CAD
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. European Heart Journal (2014) 35, 2383–2431
Patient with previous revascularization
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. European Heart Journal
(2014) 35, 2383–2431
Heart failure
30-day postoperative mortality rate was significantly higher in patients with

nonischemic HF (9.3%), ischemic HF (9.2%), and atrial fibrillation (AF) (6.4%) than
in those with CAD (2.9%)
Patients with HFpEF had a lower all-cause mortality rate than those with HFrEF
(the risk of death did not increase notably until LVEF fell below 40%)
Diastolic dysfunction with and without systolic dysfunction has been associated
with a significantly higher rate of MACE, prolonged length of stay, and higher
rates of postoperative HF
LV dysfunction
The 30-day cardiovascular event rate: symptomatic HF (49%) >
asymptomatic systolic LV dysfunction (23%)> asymptomatic diastolic LV
dysfunction (18%) > and normal LV function (10%).
Hypertension
• Uncontrolled blood pressure is one of the most common
causes of deferred operation
• A hypertensive crisis in the postoperative period poses a
definite risk for MI and cerebrovascular accident (CVA, stroke)
• Sympathetic activation can cause an increase in blood pressure
of 20–30 mm Hg and a heart rate increase of 15–20 bpm in
normotensive individuals
• Preexisting hypertension: lability of intra-operative blood
pressure, which may lead to myocardial ischaemia
• It is recommended that perioperative blood pressure be kept at
70–100% of baseline, avoiding excessive tachycardia.
• The pharmacologic should be continued perioperatively, and BP
should be maintained near preoperative levels to reduce the risk
for myocardial ischemia.
• Stage 3 hypertension should be controlled before surgery. If
surgery is more urgent, rapid-acting agents can be administered
Braunwald 11th ed
Cardiomyopathy
Restrictive cardiomyopathy
• Cardiac output : both preload and heart rate dependent
• Significant reduction of blood volume or filling pressures, bradycardia or tachycardia, and
atrial arrhythmias such as AF/ atrial flutter may not be well tolerated
HOCM
• Decreased systemic vascular resistance (arterial vasodilators), volume loss, or reduction in
preload or LV filling dynamic obstruction
ARVC
• 9,5% SCD related- ARVC occurred in perioperative
• Perioperative evaluation require cardiac electrophysiologist involvement
PPCM
• Emergency delivery may be life-saving for the mother as well as the infant
• Critically ill patients may require mechanical support with an intra-aortic balloon pump,
extracorporeal membrane oxygenation, continuous-flow LV assist devices, and/or cardiac
transplantation
Valvular Heart Disease
Volume shifts and rhythm

Hypovolemia and tachycardia and
disturbances + the surgical stress
Severe AS or MS + cardiovascular side effects of
further hemodynamic
compromise
the anesthetic medications
• Severe AS was associated with a perioperative mortality rate of 13%, compared

with 1.6% in patients without AS
• Preoperative echocardiography: quantify the severity of stenosis or regurgitation,
calculate systolic function, and estimate right heart pressure
• If necessary, treated before non-cardiac surgery
• Intraoperative and postoperative hemodynamic monitoring
Arrhythmias
• New onset ventricular arrhythmia  identifying and correcting the reversible causes (e.g.
hypoxia, hypokalemia and hypomagnesaemia)
• Sustained monomorphic VT with haemodynamic compromise must be treated promptly with
electric cardioversion
• Supraventicular arrhythmia and AF : vagal maneuver for SVT, drug therapy, or ablation
• Bradyarrhythmia: temporary or permanent cardiac pacing may be appropriate for patients with
complete heart block or symptomatic asystolic episodes. Asymptomatic bifascicular block, with
or without first-degree atrioventricular block, is not an indication for temporary pacing
Congenital heart disease in adults

▪ Pulmonary Hypertension and Eisenmenger syndrome present a major concern
▪ Preoperative evaluation performed in a regional center specializing in congenital cardiology
Stepwise approach
Surgery
STEP 3
2431
Surgery
⮚ Functional capacity measured in metabolic equivalents

(METs)
⮚ One MET equals the basal metabolic rate
⮚ Exercise testing provides an objective assessment of
functional capacity.
⮚ Without testing, functional capacity can be estimated from
the ability to perform the activities of daily living
⮚ When functional capacity is high, the prognosis is excellent,
even in the presence of stable IHD or risk factors
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. European Heart Journal (2014) 35,
2383–2431
Surgery
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. European Heart Journal
(2014) 35, 2383–2431
2431
Biomarkers
Markers focusing on myocardial ischaemia and damage, inflammation, and LV function. Even small
increases in cTnT in the perioperative period reflect clinically relevant myocardial injury with worsened
cardiac prognosis and outcome
Assessment of cardiac troponins in high-risk patients, both before and 48–72 hours after major surgery,
may therefore be considered. It should be noted that troponin elevation may also be observed in many
other conditions; the diagnosis of non-ST-segment elevation myocardial infarction should never be
made solely on the basis of biomarkers
(NT-proBNP) are produced in cardiac myocytes in response to increases in myocardial wall stress. Pre-
operative BNP and NT-proBNP levels have additional prognostic value for long-term mortality and for
cardiac events after major non-cardiac vascular surgery
(2014) 35, 2383–2431
Patients with poor exercise capacity, in contrast, may not achieve an adequate
HR and BP for diagnostic purposes on ECG stress tests  require concomitant imaging
(2014) 35, 2383–2431
Pharmacology
Beta Blockers
❖ Decrease myocardial oxygen consumption by
reducing heart rate, leading to a longer diastolic
filling period and decreased myocardial
contractility
❖ It may be reasonable to begin beta blockers long

enough in advance of the operative date that
clinical effectiveness and tolerability can be
assessed
❖ Beginning beta blockers 1 day before surgery is at

a minimum ineffective and may in fact be harmful
❖ Starting the medication 2 to 7 days before surgery

may be preferred, but few data support the need
to start beta blockers >30 days beforehand
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment
andmanagement. European Heart Journal (2014) 35, 2383–2431
Statins
• Patients with non-coronary atherosclerosis
(carotid, peripheral, aortic, renal) should
receive statin therapy for secondary
prevention, irrespective of non-cardiac
surgery.
• Statins also induce coronary plaque

stabilization through pleiotropic effects,
which may prevent plaque rupture and
subsequent myocardial infarction in the
perioperative period.
(2014) 35, 2383–2431
Ace-I & ARB
Pharmacology ACEIs did not decrease the frequency of 30-day or 1-

year death or cardiac complications after major
vascular surgery in high-risk patients
Perioperative use of ACEIs or ARBs carries a risk of

severe hypotension under anaesthesia, in particular
following induction and concomitant beta-blocker use.
In patients with LV systolic dysfunction, who are in a

stable clinical condition, it seems reasonable to
continue treatment with ACEIs under close monitoring
during the perioperative period.
If ACE inhibitors or ARBs are held before surgery, it is

reasonable to restart as soon as clinically feasible
postoperatively.
(2014) 35, 2383–2431
Anti Platelet
In subjects at risk of—or with proven—IHD, aspirin

non-adherence/withdrawal tripled the risk of major adverse cardiac
events
Delaying elective non-cardiac surgery until completion of the full

course of DAPT
Importantly, whenever possible, aspirin should be continued

throughout surgery
It is recommended that DAPT be administered for at least 1 month

after BMS implantation in stable CAD, for 6 months after new-
generation DES implantation, and for up to 1 year in patients after
ACS, irrespective of revascularization strategy
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment andmanagement. European Heart
Journal (2014) 35, 2383–2431
Anticoagulants
Vitamin K antagonists (VKAs)
- Increased the risk of peri- and post-procedural bleeding.
- If the international normalized ratio (INR) is ≤1.5, surgery can be performed safely
- Patients with a high risk of thrombo-embolism—for example, patients with:
❑ AF with a CHA2DS2-VASc [Cardiac failure, Hypertension, Age ≥75 (Doubled), Diabetes,

Stroke (Doubled) – Vascular disease, Age 65–74 and Sex category (Female)] score of ≥4]
❑ mechanical prosthetic heart valves, newly inserted biological prosthetic heart valves
❑ mitral valvular repair (within the past 3 months) or
❑ recent venous thrombo-embolism (within 3 months)
❑ thrombophilia,
Discontinuation of VKAs is hazardous and these patients will need bridging therapy
with unfractionated heparin (UFH) or therapeutic-dose LMWH
Non-vitamin K antagonist oral anticoagulants

A well-defined ‘on’ and ‘off’ action, ‘bridging’ to surgery is in most cases unnecessary, due to their
short biological half-lives
(2014) 35, 2383–2431
Thank You

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Cardiovascular Evaluation in Patients

Undergo Non-Cardiac Surgery

Resource Person: dr. Nur Haryono, SpJP (K)

Non-cardiac surgery is associated with an overall complication rate of 7–11%,

Risk of perioperative complications depends on the condition of the patient before

Demographics of patients undergoing surgery show a trend towards an increasing

Surgical procedure will produce stress response

This response is initiated by tissue injury and mediated by

Increases myocardial oxygen demand

Alterations in the balance between prothrombotic and

Increased coronary thrombogenicity

Haemodynamic derangements, leading to myocardial

Perioperative Management to Reduce Cardiovascular Events. Circulation. 2016;133:1125–1130

A time-sensitive procedure: a delay of >1 to 6 weeks to allow for an evaluation and

• length of time from MI to operation : length of time >>> postoperative MI rate

30-day postoperative mortality rate was significantly higher in patients with

Volume shifts and rhythm

• Severe AS was associated with a perioperative mortality rate of 13%, compared

Congenital heart disease in adults

⮚ Functional capacity measured in metabolic equivalents

❖ It may be reasonable to begin beta blockers long

❖ Beginning beta blockers 1 day before surgery is at

❖ Starting the medication 2 to 7 days before surgery

• Statins also induce coronary plaque

Pharmacology ACEIs did not decrease the frequency of 30-day or 1-

Perioperative use of ACEIs or ARBs carries a risk of

In patients with LV systolic dysfunction, who are in a

If ACE inhibitors or ARBs are held before surgery, it is

In subjects at risk of—or with proven—IHD, aspirin

Delaying elective non-cardiac surgery until completion of the full

Importantly, whenever possible, aspirin should be continued

It is recommended that DAPT be administered for at least 1 month

❑ AF with a CHA2DS2-VASc [Cardiac failure, Hypertension, Age ≥75 (Doubled), Diabetes,

Non-vitamin K antagonist oral anticoagulants

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