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

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 α 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.

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa

“…International guidelines promote the utility of troponin surveillance, and a recent study found troponin surveillance to be financially viable in SA. [39,40] Our data suggest that postoperative troponin surveillance is necessary in elevated-risk non-cardiac surgical patients in SA.…”

Benefits and Harms of Beta Blockers in the Perioperative Period of Non-Cardiac Surgery: A Narrative Review

“…It also warns that the tolerated beta-blocker dose before surgery is not necessarily safe because hypotension is common during or after surgery (6). The guideline has no specific recommendation about titration.…”

“…Based on this systematic review, the 2017 CCS guideline recommends against the initiation of betablockers in the last 24 hours before surgery. The guideline has no specific recommendation about when to start the drug (6).…”

“…The 2017 canadian cardiovascular society (CCS) guideline (6) states that there is a chance of increase in mortality when chronic beta-blocker therapy is interrupted in the perioperative period and thus, it recommends continuation of beta-blockers in chronic consumers. However, the guideline suggests dose reduction or holding beta-blocker consumption if the systolic blood pressure is low before surgery (6).…”

Troponin T monitoring to detect myocardial injury after noncardiac surgery: a cost–consequence analysis

“…3,4 Moreover, in the VISION study, patients with MINS who died did so a mean of 9 days after their initial troponin T level elevation, which indicates that there is time to initiate treatment after MINS is detected. Perhaps as a consequence, Canadian 5 and international 6 guidelines recommend troponin monitoring after noncardiac surgery in patients at high cardiovascular risk.…”