Society Guidelines
Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery

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Abstract

The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.

Résumé

Le comité des lignes directrices de la Société canadienne de cardiologie et les principaux leaders d'opinion canadiens ont estimé qu'il y avait un besoin pour des lignes directrices à jour utilisant le système d'évaluation des données probantes GRADE (Grading of Recommendations Assessment, Development, and Evaluation) pour l’évaluation des patients qui subissent une intervention chirurgicale non cardiaque. Les principales recommandations sont les suivantes : 1) la mesure des peptides natriurétiques de type B (BNP) ou le fragment N-terminal du propeptide natriurétique de type B (NT-proBNP) avant l’intervention chirurgicale pour améliorer l’estimation du risque cardiaque périopératoire chez les patients qui ont 65 ans ou plus, ou qui sont âgés de 45 à 64 ans et qui ont une maladie cardiovasculaire importante, ou qui ont un score RCRI (Revised Cardiac Risk Index) ≥ 1 ; 2) contre la réalisation de l’échocardiographie de repos préopératoire, l’angiographie cardiaque par tomodensitométrie, l’épreuve à l’effort ou l’épreuve d’effort cardiorespiratoire, ou l’échocardiographie de stress pharmacologique ou l’imagerie isotopique pour améliorer l’estimation du risque cardiaque périopératoire ; 3) contre l’introduction ou la continuation de l’acide acétylsalicylique pour prévenir les événements cardiaques périopératoires, excepté chez les patients ayant subi l’implantation récente d’une endoprothèse coronarienne ou qui subiront une endartériectomie carotididienne ; 4) contre l’introduction des α2-agonistes ou des β-bloqueurs dans les 24 heures qui précèdent l’intervention chirurgicale ; 5) la suspension des inhibiteurs de l’enzyme de conversion de l’angiotensine et des antagonistes des récepteurs de l’angiotensine II 24 heures avant l’intervention chirurgicale ; 6) la facilitation de l’abandon du tabac avant l’intervention chirurgicale ; 7) la mesure quotidienne de la troponine de 48 à 72 heures après l’intervention chirurgicale chez les patients qui avaient une mesure élevée des NT-proBNP/BNP avant l’intervention chirurgicale ou s’il n’y avait eu aucune mesure des NT-proBNP/BNP avant l’intervention chirurgicale, chez ceux qui ont un score RCRI ≥ 1, ou qui sont âgés de 45 à 64 ans et qui ont une maladie cardiovasculaire importante, ou qui sont âgés de 65 ans ou plus ; 8) l’introduction du traitement par acide acétylsalicylique et statines chez les patients qui souffrent de dommages myocardiques et d’infarctus après l’intervention chirurgicale.

Section snippets

Guidelines Development

The primary panel established the scope of the guidelines (ie, 4 themes: preoperative cardiac risk assessment, perioperative cardiac risk modification, monitoring for perioperative cardiac events, and management of perioperative cardiac complications), identified topics and working groups, searched the literature, developed the summary of findings and GRADE quality assessment tables, voted on the recommendations, and wrote the guidelines. The secondary panel reviewed the guidelines manuscript

Preoperative Cardiac Risk Assessment

Accurate preoperative cardiac risk estimation can serve several functions. Valid estimates of the risks and benefits of surgery can facilitate informed decision-making about the appropriateness of surgery. Accurate cardiac risk estimation can also guide management decisions (eg, consideration of endovascular vs open surgical approach) and inform decisions around monitoring (eg, troponin measurements) after surgery.

Perioperative Cardiac Risk Modification

Table 4 shows the recommended management of interventions that target perioperative cardiac risk.

Troponin monitoring

Supplemental Tables S40 and S41 show the summary of findings and GRADE quality assessment for postoperative troponin monitoring, respectively. Most myocardial infarctions occur within 48 hours of noncardiac surgery when patients are receiving analgesic medications that can mask ischemic symptoms.27 This provides an explanation as to why 65% of patients who suffer a perioperative myocardial infarction do not experience ischemic symptoms, and without perioperative troponin monitoring these

ASA and statin in patients who suffer MINS

Supplemental Tables S50 and S51 show the summary of findings and GRADE quality assessment for ASA and statin in patients who suffer MINS. One prospective cohort study and one retrospective case-control study with propensity score-matching have investigated the question of initiation of ASA and statin therapy in patients who had suffered a myocardial injury or myocardial infarction after noncardiac surgery.27, 88 In the prospective cohort study, among the 415 patients who suffered a myocardial

Conclusions and Future Research

Throughout the past 2 decades, large clinical trials and prospective observational studies have advanced our understanding of predicting, modifying the risk of, monitoring for, and managing perioperative cardiac complications. Despite these advances, cardiac complications after noncardiac surgery remain a substantial public health problem. There is a need for more large international studies to evaluate promising lines of investigation. Examples include the use of remote, automated, continuous,

Funding Sources

Funding to support a face-to-face meeting of the primary panel was supported through a McMaster University Scholar Award received by Dr Devereaux.

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    The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.

    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

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