[Skip to Content]
[Skip to Content Landing]

Perioperative Cardiac Risk Management

Learning Objectives
1. Analyze the evidence for beta-blocker therapy in the management of patients at elevated perioperative risk for cardiac events
2. Assess the role for statins in perioperative cardiac risk reduction
3. Discuss the importance of continuing cardiac medications in the perioperative setting and the role of clonidine, aspirin, and nitrates in reducing perioperative cardiac risk
4. Evaluate the role for coronary interventions in perioperative patients with documented ischemia on noninvasive cardiac testing
5. Discuss the perioperative management of antiplatelet therapy for patients with cardiac stents
6. Elucidate the typical presentation of postoperative myocardial infractions and realize the utility of screening measures
2 Credits CME

Perioperative cardiac complications are the most widely feared medical issues for the anesthesiologist, surgeon, and medical consultant as they approach a patient in the perioperative period. Only recently have management strategies been addressed in high-quality studies. The following module explains the roles of medical and interventional treatments in lowering perioperative cardiac event rates. This module also discusses the typical presentation of coronary syndromes postoperatively and the management of antiplatelet and cardiac medications.

Please finish the activity before taking the quiz.
Close

Sign in to take quiz and track your certificates

Society of Hospital Medicine Education

SHM Consults: Perioperative And Consultative Medicine curriculum can help you feel more confident about your knowledge and skills related to consultative medicine. Learn more

Activity Information

Accreditation Statement: The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Statement Designation: The Society of Hospital Medicine designates this activity for a maximum of 2.00 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Author: Dr. Cohn reports having minor stock holdings in AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Merck & Co, Inc, Pfizer Inc, and Portola; and serving on the Speakers Bureau for Janssen and Portola. Please note, there is an ongoing inquiry into publications involving Dr. Poldermans and his colleagues. The results of this inquiry may affect recommendations regarding perioperative use of β-blockers and statins. Editors (Leonard Feldman, MD, FACP, SFHM and Kurt Pfeifer, MD, FACP, SFHM): Dr. Feldman reports having no relevant financial or advisory relationships with corporate organizations related to this activity. Dr. Pfeifer reports having no relevant financial or advisory relationships with corporate organizations related to this activity. The planners and faculty for this activity have no relevant relationships to disclose unless otherwise listed.

SHM COI Policy: In accordance with the ACCME Standards for Commercial Support, SHM requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. SHM resolves all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. All relevant financial relationships shall be disclosed to participants prior to the start of the activity. Furthermore, SHM seeks to verify that all scientific research referred to, reported, or used in a continuing medical education (CME) activity conforms to the generally accepted standards of experimental design, data collection, and analysis. SHM is committed to providing its learners with high-quality CME activities that promote improvements in healthcare and not those of a commercial interest.

References:
1.
Mangano  DT, Layug  EL, Wallace  A,  et al.  Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group.  N Engl J Med. 1996;335:1713–1720.Google Scholar
2.
Poldermans  D, Boersma  E, Bax  JJ,  et al.  The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group.  N Engl J Med. 1999;341:1789–1794.Google Scholar
3.
Boersma  E, Poldermans  D, Bax  JJ,  et al.  Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy.  JAMA. 2001;285:1865–1873.Google Scholar
4.
Juul  AB, Wetterslev  J, Gluud  C,  et al.  Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomized placebo controlled, blinded multicentre trial.  BMJ. 2006;332:1482.Google Scholar
5.
Yang  H, Raymer  K, Butler  R,  et al.  The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial.  Am Heart J. 2006;152:983–990.Google Scholar
6.
Devereaux  PJ, Yang  H, Yusuf  S,  et al.  Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial.  Lancet. 2008;371:1839–1847.Google Scholar
7.
Wijeysundera  DN, Duncan  D, Nkonde-Price  C,  et al.  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: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.  J Am Coll Cardiol. 2014;64:2406–2425.Google Scholar
8.
Kristensen  SD, Knuuti  J, Saraste  A,  et al.  2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA).  Eur Heart J. 2014;35:2383–2431.Google Scholar
9.
 POISE-2 Trials: Evaluation of Low-Dose Clonidine and Aspirin in Patients at Risk for ASCVD.  The American College of Cardiology Web site. Available at: http://www.acc.org/latest-incardiology/articles/2014/03/28/16/44/poise-2-trials-aspirin-and-clonidine-impacts-majorarterial-events-in-noncardiac-surgery-patients. Published March29 , 2014. Accessed April 6, 2015.Google Scholar
10.
Shammash  JB, Trost  JC, Gold  JM,  et al.  Perioperative beta-blocker withdrawal and mortality in vascular surgical patients.  Am Heart J. 2001;141:148-153.Google Scholar
11.
Fleischmann  KE, Beckman  JA, Buller  CE,  et al.  2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.  Circulation. 2009;120:2123–2151.Google Scholar
12.
Lindenauer  PK, Pekow  P, Wang  K,  et al.  Perioperative beta-blocker therapy and mortality after major noncardiac surgery.  N Engl J Med. 2005;353:349–361.Google Scholar
13.
Poldermans  D, Bax  JJ, Boersma  E,  et al.  Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).  Eur Heart J. 2009;30:2769–2812. Available at: http://eurheartj.oxfordjournals.org/content/early/2009/08/27/eurheartj.ehp337.full.pdf+html. Accessed October 1, 2010.Google Scholar
14.
London  MJ, Hur  K, Schwartz  GG,  et al.  Association of perioperative β-blockade with mortality and cardiovascular morbidity following major noncardiac surgery.  JAMA. 2013;309:1704– 1713.Google Scholar
15.
Redelmeier  D, Scales  D, Kopp  A.  Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study.  BMJ. 2005;331:932.Google Scholar
16.
Mashour  GA, Sharifpour  M, Freundlich  RE,  et al.  Perioperative metoprolol and risk of stroke after noncardiac surgery.  Anesthesiology. 2013;119:1340–1346.Google Scholar
17.
Dunkelgrun  M, Boersma  E, Schouten  O,  et al.  Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV).  Ann Surg. 2009;249:921–926.Google Scholar
18.
Wallace  A, Layug  B, Tateo  I,  et al.  Prophylactic atenolol reduces postoperative myocardial ischemia.  Anesthesiology. 1998;88:7–17.Google Scholar
19.
POBBLE Trial Investigators.  Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial.  J Vasc Surg. 2005;41:602–609.Google Scholar
20.
Poldermans  D, Bax  JJ, Schouten  O,  et al.  Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control?  J Am Coll Cardiol. 2006;48:964–969.Google Scholar
21.
Fox  K, Ford  I, Steg  PG,  et al; BEAUTIFUL Investigators.  Ivabradine for patients with stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a randomized, double-blind, placebo-controlled trial.  Lancet. 2008;372:807–816.Google Scholar
22.
Fleisher  LA, Fleischmann  KE, Auerbach  AD,  et al; American College of Cardiology; American Heart Association.  2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.  J Am Coll Cardiol. 2014;64:e77–e137.Google Scholar
23.
Poldermans  D, Bax  JJ, Kertai  MD,  et al.  Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery.  Circulation. 2003;107:1848–1851.Google Scholar
24.
Lindenauer  PK, Pekow  P, Wang  K,  et al.  Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery.  JAMA. 2004;291:2092–2099.Google Scholar
25.
Fleisher  LA, Beckman  JA, Brown  KA,  et al.  ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.  Circulation. 2007;116:e418–e499.Google Scholar
26.
Durazzo  AE, Machado  FS, Ikeoka  DT,  et al.  Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial.  J Vasc Surg. 2004;39:967-975; discussion 975– 966.Google Scholar
27.
Schouton  O, Boersma  E, Hoeks  SE,  et al.  Fluvastatin and perioperative events in patients undergoing vascular surgery.  N Engl J Med. 2009;360:980–989.Google Scholar
28.
Ridker  PM, Rifai  N, Lowenthal  SP.  Rapid reduction in C-reactive protein with cerivastatin among 785 patients with primary hypercholesterolemia.  Circulation. 2001;103:1191–1193.Google Scholar
29.
O'Driscoll  G, Green  D, Taylor  RR.  Simvastatin, an HMG-coenzyme A reductase inhibitor, improves endothelial function within 1 month.  Circulation. 1997;95:1126–1131.Google Scholar
30.
Schouten  O, Kertai  MD, Bax  JJ,  et al.  Safety of perioperative statin use in high-risk patients undergoing major vascular surgery.  Am J Cardiol. 2005;95:658–660.Google Scholar
31.
Grundy  SM, Cleeman  JI, Merz  CN,  et al.  Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines.  Arterioscler Thromb Vasc Biol. 2004;24:e149–e161.Google Scholar
32.
Stone  NJ, Robinson  JG, Lichtenstein  AH,  et al.  2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.  J Am Coll Cardiol. 2014;63:2889–2934.Google Scholar
33.
Le Manach  Y, Godet  G, Coriat  P,  et al.  The impact of postoperative discontinuation or continuation of chronic statin therapy on cardiac outcome after major vascular surgery.  Anesth Analg. 2007;104:1326–1333.Google Scholar
34.
Fonarow  GC, Wright  RS, Spencer  FA,  et al.  Effect of statin use within the first 24 hours of admission for acute myocardial infarction on early morbidity and mortality.  Am J Cardiol. 2005;96:611–616.Google Scholar
35.
Iakovou  I, Schmidt  T, Bonizzoni  E,  et al.  Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents.  JAMA. 2005;293:2126–2130.Google Scholar
36.
Devereaux  PJ, Mrkobrada  M, Sessler  DI,  et al; POISE-2 Investigators.  Aspirin in patients undergoing noncardiac surgery.  N Engl J Med. 2014;370:1494–1503.Google Scholar
37.
Dodds  TM, Stone  JG, Coromilas  J,  et al.  Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia.  Anesth Analg. 1993;76:705–713.Google Scholar
38.
Ellis  JE, Drijvers  G, Pedlow  S,  et al.  Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis.  Anesth Analg. 1994;79:1133–1140.Google Scholar
39.
Stuhmeier  KD, Mainzer  B, Cierpka  J,  et al.  Small, oral dose of clonidine reduces the incidence of intraoperative myocardial ischemia in patients having vascular surgery.  Anesthesiology. 1996;85:706–712.Google Scholar
40.
Wallace  AW, Galindez  D, Salahieh  A,  et al.  Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery.  Anesthesiology. 2004;101:284–293.Google Scholar
41.
Schouten  O, van Kuijk  JP, Flu  WJ,  et al.  Long-term outcome of prophylactic coronary revascularization in cardiac high-risk patients undergoing major vascular surgery (from the randomized DECREASE-V Pilot Study).  Am J Cardiol. 2009;103:897–901.Google Scholar
42.
McFalls  EO, Ward  HB, Moritz  TE,  et al.  Coronary-artery revascularization before elective major vascular surgery.  N Engl J Med. 2004;351:2795–2804.Google Scholar
43.
Poldermans  D, Schouten  O, Vidakovic  R,  et al.  A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study.  J Am Coll Cardiol. 2007;49:1763–1769.Google Scholar
44.
Vicenzi  MN, Meislitzer  T, Heitzinger  B,  et al.  Coronary artery stenting and non-cardiac surgery-a prospective outcome study.  Br J Anaesth. 2006;96:686–693.Google Scholar
45.
Dawood  MM, Gutpa  DK, Southern  J,  et al.  Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention.  Int J Cardiol. 1996;57:37– 44.Google Scholar
46.
Poldermans  D, Boersma  E, Bax  JJ,  et al.  Correlation of location of acute myocardial infarct after noncardiac vascular surgery with preoperative dobutamine echocardiographic findings.  Am J Cardiol. 2001;88:1413–1414, A1416.Google Scholar
47.
Eagle  KA, Rihal  CS, Mickel  MC,  et al.  Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study.  Circulation. 1997;96:1882–1887.Google Scholar
48.
Grines  CL, Bonow  RO, Casey  DE  Jr, ,  et al.  Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians.  Circulation. 2007;115:813–818.Google Scholar
49.
Nuttall  GA, Brown  MJ, Stombough  JW.  Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention.  Anesthesiology. 2008;109:588–595.Google Scholar
50.
Holcomb  CN, Graham  LA, Richman  JS  et al.  The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting.  J Am Coll Cardiol. 2014;64:2730–2739.Google Scholar
51.
Hawn  MT, Graham  LA, Richman  JS,  et al.  Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents.  JAMA. 2013;310:1462–1472.Google Scholar
52.
Eisenberg  MJ, Richard  PR, Libersan  D,  et al.  Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents.  Circulation. 2009;119:1634–1642.Google Scholar
53.
Burger  W, Chemnitius  JM, Kneissl  G,  et al.  Low-dose aspirin for secondary cardiovascular revention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis.  J Intern Med. 2005;257:399–414Google Scholar
54.
Aguejouf  O, Malfatti  E, Belon  P,  et al.  Time related neutralization of two doses acetyl salicylic acid.  Thromb Res. 2000;100:317–323.Google Scholar
55.
Fox  KA, Mehta  SR, Peters  R,  et al.  Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial.  Circulation. 2004;110:1202–1208.Google Scholar
56.
Yende  S, Wunderink  RG.  Effect of clopidogrel on bleeding after coronary artery bypass surgery.  Crit Med. 2001;29:2271–2275.Google Scholar
57.
Horlocker  T, Wedel  DJ, Benzon  H,  et al.  Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation).  Reg Anesth Pain Med. 2003;28:172–197.Google Scholar
58.
Devereaux  PJ, Xavier  D, Pogue  J,  et al; POISE (PeriOperative ISchemic Evaluation) Investigators.  Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.  Ann Intern Med. 2011;154:523– 528.Google Scholar
59.
Ashton  CM, Petersen  NJ, Wray  NP,  et al.  The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery.  Ann Intern Med. 1993;118:504–510.Google Scholar
60.
Badner  NH, Knill  RL, Brown  JE,  et al.  Myocardial infarction after noncardiac surgery.  Anesthesiology. 1998;88:572–578.Google Scholar
61.
Rinfret  S, Goldman  L, Polanczyk  CA,  et al.  Value of immediate postoperative electrocardiogram to update risk stratification after major noncardiac surgery.  Am J Cardiol. 2004;94:1017–1022.Google Scholar
62.
Landesberg  G, Shatz  V, Akopnik  I,  et al.  Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery.  J Am Coll Cardiol. 2003;42:1547–1554.Google Scholar
63.
Devereaux  PJ, Chan  MT, Alonso-Coello  P,  et al; Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators.  Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.  JAMA.2012;307:2295-2304.Google Scholar
64.
Botto  F, Alonso-Coello  P, Chan  MT,  et al.  Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, (VISION) Investigators; Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.  Anesthesiology. 2014;120:564–578.Google Scholar
65.
Lopez-Jimenez  F, Goldman  L, Sacks  DB,  et al.  Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data.  J Am Coll Cardiol. 1997;29:1241–1245.Google Scholar
66.
Foucrier  A, Rodseth  R, Aissaoui  M, I  et al.  The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery.  Anesth Analg. 2014;119:1053–1063.Google Scholar
67.
Jørgensen  ME, Sanders  RD, Køber  L, Mehta  K, Torp-Pedersen  C, Hlatky  MA, Pallisgaard  JL, Shaw  RE, Gislason  GH, Jensen  PF, Andersson  C.  Beta-blocker subtype and risks of perioperative adverse events following non-cardiac surgery: a nationwide cohort study.  Eur Heart J. 2017 Aug14 ;38(31):2421–2428. PMID: PubMed.Google Scholar
68.
London  MJ, Schwartz  GG, Hur  K, Henderson  WG.  Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery.  JAMA Intern Med. 2017 Feb1 ;177(2):231– 242. PMID: PubMed.Google Scholar
69.
Berwanger  O, Le Manach  Y, Suzumura  EA,  et al; VISION Investigators.  Association between pre-operative statin use and major cardiovascular complications among patients undergoing noncardiac surgery: the VISION study.  Eur Heart J. 2016;37(2):177–185. PMID: PubMed.Google Scholar
70.
Xia  J, Qu  Y, Yin  C, Xu  D.  Preoperative rosuvastatin protects patients with coronary artery disease undergoing noncardiac surgery.  Cardiology. 2015;131(1):30–7. PMID: PubMed.Google Scholar
71.
Xia  J, Qu  Y, Shen  H, Liu  X.  Patients with stable coronary artery disease receiving chronic statin treatment who are undergoing noncardiac emergency surgery benefit from acute atorvastatin reload.  Cardiology. 2014;128(3):285–92.PMID: PubMed.Google Scholar
72.
Berwanger  O, de Barros E Silva  PG, Barbosa  RR,  et al; LOAD Investigators.  Atorvastatin for highrisk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial.  Am Heart J. 2017 Feb;184:88–96. PMID: PubMed.Google Scholar
73.
Graham  MM, Sessler  DI, Parlow  JL,  et al.  Aspirin in Patients With Previous Percutaneous Coronary Intervention Undergoing Noncardiac Surgery.  Ann Intern Med. 2018 Feb20 ;168(4):237– 244. PMID: PubMed.Google Scholar
74.
Devereaux  PJ, Duceppe  E, Guyatt  G, Tandon  V, Rodseth  R, Biccard  BM, Xavier  D, Szczeklik  W, Meyhoff  CS, Vincent  J, Franzosi  MG, Srinathan  SK, Erb  J, Magloire  P, Neary  J, Rao  M, Rahate  PV, Chaudhry  NK, Mayosi  B, de Nadal  M, Iglesias  PP, Berwanger  O, Villar  JC, Botto  F, Eikelboom  JW, Sessler  DI, Kearon  C, Pettit  S, Sharma  M, Connolly  SJ, Bangdiwala  SI, Rao-Melacini  P, Hoeft  A, Yusuf  S; MANAGE Investigators.  Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial.  Lancet. 2018 Jun9 ;391(10137):2325–2334. PMID: PubMedGoogle Scholar
Close
Close

Name Your Search

Save Search
Close
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
Close