Preoperative Evaluation for Noncardiac Surgery.

This issue provides a clinical overview of preoperative evaluation for noncardiac surgery, focusing on risk factors, elements of evaluation, medication management, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Update in perioperative cardiac medicine 2021.

Several studies published in the last year have shed light on the preoperative assessment of perioperative cardiovascular risk and on the need for anticoagulation in patients with postoperative atrial fibrillation, which are reviewed here.

Variations in pharmacology of beta-blockers may contribute to heterogeneous results in trials of perioperative beta-blockade.

BACKGROUND: Randomized controlled trials and meta-analyses provide conflicting guidance on the role of beta-adrenergic receptor blockers (beta-blockers) in reducing perioperative complications. We hypothesize that variability in trial results may be due in part to heterogeneous properties of beta-blockers. First, we propose that the extent of beta-blocker metabolism by cytochrome P-450 and the time available to titrate the dosage before surgery (titration time) may interact; dependence on P-450 may be most harmful when titration time is short. Second, beta-blockers vary in their selectivity for the beta-1 receptor and reduced selectivity may contribute to cerebral ischemia. METHODS: We used meta-analysis and meta-regression of existing trials to explore the role of these pharmacological properties. RESULTS: We found that both of these pharmacological factors are significantly associated with reduced efficacy of beta-blockers. CONCLUSIONS: Pharmacological properties of beta-blockers may contribute to heterogeneous trial results. Many trials have used metoprolol, which is extensively metabolized by cytochrome P450 and is less selective for the beta-1 receptor. For these two reasons, the efficacy of metoprolol to prevent perioperative cardiac complications should be compared with the efficacy of other beta-blockers.

2019 Update in perioperative cardiovascular medicine.

We performed a MEDLINE search and found 6 studies published February 2018 through January 2019 that should influence perioperative cardiovascular medicine, specifically in preoperative cardiac risk assessment, perioperative medication management, and postoperative cardiac complications.

Preoperative cardiac evaluation of lung resection candidates.

Patients who have lung cancer typically have both pulmonary and cardiac disease as a result of cigarette smoking and are potentially at increased risk for perioperative cardiopulmonary complications. Knowledge of risk factors and a careful preoperative assessment will help the medical team stratify the patient's level of risk and employ measures to minimize surgical risk. The available literature specific to cardiac risk and lung cancer surgery is minimal, but the general principles of preoperative cardiac risk evaluation and perioperative management have been reviewed. When considering cardiac testing and interventions, the medical consultant must remember that surgery is the treatment of choice for non-small cell lung cancer and must avoid any excessive delay that might compromise the patient's chance of a surgical cure.

Comparison of 4 Cardiac Risk Calculators in Predicting Postoperative Cardiac Complications After Noncardiac Operations.

The 2014 American College of Cardiology/American Heart Association Perioperative Guidelines suggest using the Revised Cardiac Risk Index, myocardial infarction or cardiac arrest, or American College of Surgeons-National Surgical Quality Improvement Program calculators for combined patient-surgical risk assessment. There are no published data comparing their performance. This study compared these risk calculators and a reconstructed Revised Cardiac Risk Index in predicting postoperative cardiac complications, both during hospitalization and 30 days after operation, in a patient cohort who underwent select surgical procedures in various risk categories. Cardiac complications occurred in 14 of 663 patients (2.1%), of which 11 occurred during hospitalization. Only 3 of 663 patients (0.45%) had a myocardial infarction or cardiac arrest. Because these calculators used different risk factors, different outcomes, and different durations of observation, a true direct comparison is not possible. We found that all 4 risk calculators performed well in the setting they were originally studied but were less accurate when applied in a different manner. In conclusion, all calculators were useful in defining low-risk patients in whom further cardiac testing was unnecessary, and the myocardial infarction or cardiac arrest may be the most reliable in selecting higher risk patients.

Perioperative cardiovascular medicine: 5 questions for 2018.

A MEDLINE search was performed from January 2017 to February 2018, and articles were selected for this update based on their significant influence on the practice of perioperative cardiovascular medicine.

2017 Update in perioperative medicine: 6 questions answered.

The authors performed a MEDLINE search to identify articles published between January 2016 and April 2017 that had significant impact on perioperative care. They identified 6 topics for discussion.

Cardiac risk stratification before noncardiac surgery.

The history and the physical examination remain the most important elements in cardiac risk stratification of patients prior to noncardiac surgery. Indications for further cardiac tests and interventions are usually the same as in the nonsurgical setting. No test should be performed unless the results will affect patient management. In many cases, noninvasive testing is being replaced by prophylactic medical therapy, a topic explored in the next article in this supplement.

Update in perioperative cardiac medicine.

Recent studies have shed light on preoperative risk assessment, medical therapy to reduce postoperative cardiac complications (beta-blockers, statins, and angiotensin II receptor blockers [ARBs]), perioperative management of patients with coronary stents on antiplatelet therapy, and perioperative bridging anticoagulation.

Updates in perioperative medicine.

BACKGROUND: As our surgical population becomes older and more medically complex, knowledge of the most recent perioperative literature is necessary to optimize perioperative care. We aim to summarize and critique literature published over the past year with the highest potential to impact the clinical practice of perioperative medicine. METHODS: We reviewed articles published between January 2014 and April 2015, identified via MEDLINE search. The final 10 articles selected were determined by consensus among all authors, with criteria for inclusion including scientific rigor and relevance to perioperative medicine practice. RESULTS: Key findings include: long term ß-blockade should be continued prior to surgery, routine screening with postoperative troponin is not recommended, initiation/continuation of aspirin or clonidine in the perioperative period is not beneficial and may increase adverse outcomes, preoperative diagnosis and treatment of obstructive sleep apnea may reduce risk of postoperative cardiovascular complications, new pulmonary risk indices are available that accurately estimate postoperative pulmonary complications, postoperative atrial fibrillation is associated with increased long-term stroke risk, risk scores such as the CHADS2 (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes Mellitus, previous stroke or transient ischemic attack) are superior to the Revised Cardiac Risk Index in predicting adverse postoperative outcomes for patients with nonvalvular atrial fibrillation, and utilization of bridging anticoagulation comes with a much higher risk of bleeding compared to patients who are not bridged. CONCLUSIONS: The body of literature reviewed provides important information for clinicians caring for surgical patients across multiple fronts, including preoperative risk assessment, medication management, and postoperative medical care.

Stroke prevention in atrial fibrillation: current anticoagulation management and future directions.

Atrial fibrillation (AF) is an important cause of stroke, and stroke risk stratification is critical to the management of patients with AF. Anticoagulation with warfarin is the current standard of care for stroke prevention in these patients, despite the need for close monitoring. Aspirin alone is not as effective. Warfarin is recommended for patients with AF and valvular disease or with AF and one or more stroke risk factors. Other novel anticoagulants and antiplatelet combinations are under investigation. Curative procedures for AF are possible, but their long-term safety and effect on stroke risk are unknown.

The role of the medical consultant.

The basic concepts of medical consultation have been reviewed. The referring physician and the consultant both have responsibilities to fulfill in order to maximize the effectiveness of the consultation in improving patient care. The reasons for and urgency of the consultation need to be communicated to and understood by the consultant. The consultant needs to respond by promptly evaluating the patient, concisely documenting his findings, and communicating his recommendations to the referring physician. As described by Bates, the ideal medical consultant will "render a report that informs without patronizing, educates without lecturing, directs without ordering, and solves the problem without making the referring physician appear to be stupid". The consultant should try to support the referring physician and comfort the patient. By following these guidelines, the consultant will be more effective in providing useful, informative advice likely to result in enhanced compliance with the recommendations and improved patient outcome.