Pre‐operative cardiac optimisation: a directed review

Abstract

Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. Peri-operative management of antihypertensive drugs in keeping with the current best evidence is discussed. Pre-operative cardiac risk assessment and cardiac biomarkers can be used to help predict and quantify peri-operative adverse cardiac events. There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.

Ocena kardiologiczna kandydatów do przeszczepienia wątroby

“…Therefore, patients with liver cirrhosis during evaluation for liver transplantation (LT), according to the European Cardiac Society (ESC) recommendations, undergo a detailed cardiac diagnostics due to the extent of surgery and the existence of multiple co-morbidities, which are also risk factors for CAD. Liver transplant candidates are in the high risk group of cardiovascular events in the perioperative period (a greater than 5% 30-day risk of myocardial infarction, cardiac arrest, life-threatening arrhythmias, stroke and death from cardiovascular causes) due to vascular changes after transplantation such as increased systemic vascular resistance, decreased cardiac output and increased pulmonary capillary wedge pressure [5][6][7][8].…”

Pre‐operative transthoracic echocardiography in ambulatory surgery—A cross‐sectional study

“…The significant impact of focused pre‐operative TTE has previously been described 14,17,18,24 . Pre‐operative identification of high‐risk patients enables an individualized anesthesia management, and may play a key role in minimizing perioperative complications 29 . Nonetheless, at present, the use of TTE in pre‐operative clinical praxis is not a routine approach, and clear indications are lacking.…”

Peri‐operative ventricular bigeminy and cardiomyopathy in elective surgery

“…Strong associations have been described for many years between PVCs and stroke, coronary artery disease and sudden cardiac death . This prompted speculation in the cardiology community that, at least in some instances, and particularly when longstanding, PVCs may be less benign than previously thought and could possibly induce underlying structural heart disease . The most compelling observation has been the improvement in cardiac function observed in some patients following the suppression of PVCs with pharmacological or interventional treatment.…”

“…Furthermore, patients with a high frequency of PVCs are at risk of arrhythmias and sudden cardiac death. Appropriate investigation and optimisation are therefore essential before even minor elective surgical procedures .…”