Perioperative cardiac risk assessment for noncardiac surgery.

Patients with coronary artery disease who undergo noncardiac surgery are at risk of cardiac complications. It is, therefore, imperative to assess the risk of noncardiac surgery in these patients in a variety of operative settings. We propose a simplified approach at perioperative risk assessment that ascertains risks based on the need and urgency of surgery, and the type of surgery. Furthermore, we suggest guidelines for perioperative risk assessment based on patient's history and physical exam, their functional capacity and prior procedures. Based on these clinical data, we identify patients into three categories for a cardiac event during noncardiac surgery: high, intermediate and low risk groups. We recommend that all urgent surgeries should be carried out with attempts made at proper perioperative management to reduce the risk of cardiac events. Further, low or intermediate risk patients undergoing minor surgery should be operated without any further cardiac evaluation. Intermediate risk patients, who need an intermediate or major surgery, should undergo a stress test to evaluate for ischemia. If there is evidence of a large ischemic burden and those patients at high risk should undergo cardiac catheterization and appropriate intervention. We also suggest methods of modifying risk in the perioperative period for all patients to reduce perioperative cardiac events with proper monitoring and use of medications including beta blockers. This article provides a detailed review on the current literature supporting the stepwise approach proposed by us.