Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today’s health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today's health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

Cardiovascular comorbidities are amongst the most important modifiable risk factors in patients undergoing non-cardiac surgery. Likewise, cardiac complications are a leading cause of all perioperative morbidity and mortality. Major adverse events include acute myocardial ischaemia, infarction, congestive cardiac failure, arrhythmias, and cardiac arrest. Preoperative assessment and planning aims to minimize these risks. Although testing is important, it must be rationalized lest resources are misused and undue delays ensue. Current thinking in preoperative therapy, intraoperative management and postoperative care is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and principles of their management are briefly considered.     

Assessment of elective patients

This article outlines an approach to preoperative assessment of patients presenting for elective surgery. The main focus is on assessment of patients with cardiovascular disease undergoing non-cardiac surgery, with regard to risk assessment, preoperative investigations and perioperative management of cardiovascular medications. Assessment of patients with common respiratory diseases, including obstructive sleep apnoea, is also discussed. The current utility of cardiopulmonary exercise testing in risk assessment and perioperative care planning is summarized. Finally, use of brain natriuretic peptide as a biomarker in risk stratification is considered.     

Perioperative management of the patient with cardiovascular disease undergoing non-cardiac surgery

Cardiac morbidity and mortality account for a significant proportion of complications after non-cardiac surgery. Risk assessment allows selection of patients who would benefit from preoperative optimization, further investigations or intervention. With the increased use of coronary stents and concomitant antiplatelet agents it is important to appraise the risks and benefits of different management strategies prior to non-cardiac surgery. A stepwise approach to preoperative cardiac risk assessment and risk reduction strategies is highlighted.     

Preoperative investigations in adult cardiac surgery patients

Preoperative investigations in cardiac surgery can be divided into diagnostic studies and assessment of fitness for surgery. Diagnostic investigations are used to detect and evaluate coronary, valvular, myocardial and thoracic aortic disease. Knowledge of an individual patient’s co-morbidities helps to determine the risk of postoperative morbidity and mortality, and allows for more accurate informed consent. Furthermore, the results of preoperative investigations may predict the likely postoperative support required in order to maximize the chances of uneventful recovery. New innovations such as transcatheter aortic valve implantation (TAVI) procedure are increasingly being used as alternatives to open heart surgery for very high-risk patients with severe aortic stenosis. This contribution highlights the tests for preoperative diagnosis and assessment of fitness for surgery in adult cardiac patients. In combination they guide clinicians in making appropriate management decisions, particularly with regard to elderly, frail or complex cardiac cases discussed in the setting of joint cardiology and cardiothoracic meetings.     

Diagnostic investigations of adult cardiac disease

Preoperative investigations in cardiac surgery can be divided into two stages: diagnostic studies and assessment of fitness for surgery. Diagnostic investigations are used by cardiologists to detect and evaluate coronary, valvular, myocardial and thoracic aortic disease and, in conjunction with symptoms, are used to determine the appropriate management of cardiovascular disease. Patients presenting for cardiac surgery frequently have significant co-morbidities. Knowledge of these co-morbidities helps to plan the perioperative care of the patient with the aim of reducing postoperative morbidity and mortality thereby maximizing the chances of an uneventful recovery, and allows for more accurate informed consent. The preoperative assessment may also determine a patient to be very high risk for conventional treatment and may steer clinicians to offer patients alternative treatments such as transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. This article highlights the tests for preoperative diagnosis and assessment of fitness for surgery in adult cardiac patients. In combination they guide clinicians in making appropriate management decisions, particularly with regard to elderly, frail or complex cardiac cases discussed in the setting of joint cardiology and cardiothoracic meetings.     

Principles of preoperative assessment and enhanced recovery optimization for thoracic anaesthesia

A comprehensive preoperative assessment is imperative for patients undergoing lung surgery, ideally by way of a multidisciplinary team approach. This not only allows for clinicians to risk stratify patients and gain informed consent, but also to explore avenues in optimizing patients prior to surgery and plan for the delivery of the most appropriate postoperative care. A tripartite risk assessment combining risks of operative mortality, perioperative adverse cardiac events and postoperative dyspnoea should be assessed and discussed with patients. Those patients who continue towards surgical management may then be optimized with patient education addressing nutritional status, smoking cessation and alcohol dependency as well as the management of anaemia and physiological prehabilitation. This article aims to review existing guidelines for preoperative assessment in thoracic surgery as well as the latest preoperative guidance for enhanced recovery specific to thoracic surgery.     

Perioperative management of the patient with cardiovascular disease undergoing non-cardiac surgery

Cardiac complications are the most common cause of postoperative morbidity and mortality. Thorough preoperative risk assessment and stratification allow clear identification of higher risk patients who would benefit from preoperative optimization and risk reduction strategies. Newer investigations improve the predictive value of contemporary risk indices. Atrial fibrillation and heart failure pose more risk than previously thought, even for minor non-cardiac surgery.     

Perioperative management of the patient with cardiovascular disease undergoing non-cardiac surgery

Cardiac complications are the most common cause of postoperative morbidity and mortality. Thorough preoperative risk assessment and stratification allows clear identification of higher risk patients who would benefit from preoperative optimization and risk reduction strategies. Newer investigations improve the predictive value of contemporary risk indices. Atrial fibrillation and heart failure pose more risk than previously thought, even for minor non-cardiac surgery.     

Preoperative assessment for cardiac surgery

Anaesthetic challenges in cardiac surgery are multifaceted. Since patients present with compromised cardiovascular reserve and multiple comorbidities, a thorough preoperative assessment and meticulous anaesthetic plan is essential. This targets anaesthetic history, physical examination and analysis of investigations, routine and specific to the cardiovascular system. Special models exist for risk stratification to aid perioperative planning, surgical decision making, benchmarking and quality assurance. This article provides an overview of history, examination and preoperative management of patients undergoing cardiac surgery. Scoring systems and practical investigations are reviewed.     

Preoperative assessment for cardiac surgery

Anaesthetic challenges in cardiac surgery are multifaceted. Since patients present with compromised cardiovascular reserve and multiple co-morbidities, a thorough preoperative assessment and meticulous anaesthetic plan is essential. This targets anaesthetic history, physical examination and analysis of investigations, routine and specific to the cardiovascular system. Special models exist for risk stratification to aid perioperative planning, surgical decision making, benchmarking and quality assurance. This article provides an overview of history, examination and preoperative management of patients undergoing cardiac surgery. Scoring systems and practical investigations are reviewed.     

Preoperative assessment for thoracic anaesthesia

Preoperative assessment of patients for thoracic surgery is a multidisciplinary process designed to offer appropriate surgical treatment with acceptable risk. UK guidelines for pulmonary resection associated with malignant disease involved review of available evidence concerning operative risk. Patients displaying cardiopulmonary physiological parameters above previously recommended threshold values remain classified as acceptable risk. However, less certainty exists about the utility of predicted postoperative pulmonary function values and preoperative performance status to confer unacceptable risk. These guidelines suggest a tri-partite risk assessment combining risks of operative mortality, perioperative adverse cardiac events and postoperative dyspnoea, to be discussed by the multidisciplinary team and with the patient.     

呼吸功能不全病人术前相关功能评价

对合并肺功能不全病人的术前评估,应对个人的具体情况作出判断,以降低手术的风险。包括：6min步行试验、胸部CT检查、肺通气功能、肺弥散功能、放射性核素肺通气、肺血流灌注显像及运动性心肺功能检查等有助于做出正确的判断。最稳妥的办法是术前心脏、呼吸及麻醉专业的医生共同评价手术风险及预后。     

Preoperative evaluation of the patient with cardiorespiratory diseases

Cardiorespiratory complications are amongst the most common causes of postoperative morbidity and mortality and impose a significant financial burden on the NHS. Patients with premorbid cardiorespiratory diseases can be identified preoperatively with a thorough history taking along with targeted investigations. Preoperative evaluation, risk assessment and stratification allow for clear identification of higher risk patients who would benefit from preoperative medical optimization, appropriate planning of perioperative care including anaesthetic management, modification of surgical procedure, and the level of postoperative care required as a part of risk reduction strategies.     

Preoperative evaluation of patients with,or at risk of,coronary artery disease undergoing non-cardiac surgery

The increasing number of patients with coronary artery diseaseundergoing major non-cardiac surgery justifies guidelines concerningpreoperative evaluation, stress testing, coronary angiography,and revascularization. A review of the recent literature showsthat stress testing should be limited to patients with suspicionof a myocardium at risk of ischaemia, and coronary angiographyto situations where revascularization can improve long-termsurvival. Recent data have shown that any event in the coronarycirculation, be it new ischaemia, infarction, or revascularization,induces a high-risk period of 6 weeks, and an intermediate-riskperiod of 3 months. A 3-month minimum delay is therefore indicatedbefore performing non-cardiac surgery after myocardial infarctionor revascularization. However, this delay may be too long ifan urgent surgical procedure is requested, as for instance withrapidly spreading tumours, impending aneurysm rupture, infectionsrequiring drainage, or bone fractures. It is then appropriateto use perioperative beta-block, which reduces the cardiac complicationrate in patients with, or at risk of, coronary artery disease.The objective of this review is to offer a comprehensive algorithmto help clinicians in the preoperative assessment of patientsundergoing non-cardiac surgery. Br J Anaesth 2002; 89: 747–59     

Preoperative evaluation of the patient with cardiorespiratory diseases

Cardiorespiratory complications are among the most common causes of postoperative morbidity and mortality and impose a significant financial burden on the NHS. Patients with premorbid cardiorespiratory diseases can be identified preoperatively with a thorough history taking along with targeted investigations. Preoperative evaluation, risk assessment and stratification allows for clear identification of higher risk patients who would benefit from preoperative medical optimization, appropriate planning of perioperative care including anaesthetic management, modification of surgical procedure and the level of postoperative care required as a part of risk reduction strategies.     

Cardiac risk reduction in non-cardiac surgery: the role of anaesthesia and monitoring techniques

Cardiac complications are the major cause of perioperative morbidity and mortality of patients undergoing non-cardiac surgery. This is related to the frequent presence of underlying coronary artery disease. In the last few decades, attention has focused on preoperative cardiac risk assessment that may help to identify patients at increased cardiac risk for whom cardioprotective medication and, when indicated, coronary revascularization may improve perioperative outcome. On the other hand, less attention was given to the role of anaesthesia and monitoring techniques in the cardiac risk management of high-risk patients undergoing non-cardiac surgery. The aim of this review was to summarize the current evidence from published studies on the effect of the type of anaesthesia and monitoring techniques on perioperative cardiac outcome in non-cardiac surgery.     

Preoperative assessment for cardiac surgery

Patients presenting for cardiac surgery pose several challenges for the anaesthetist. Not only are they preparing for major surgery to improve impaired cardiovascular function, but many also suffer from significant co-morbid disease. Thorough preoperative assessment and investigation is imperative. This allows identification of those patients at high risk of perioperative complications, and promotes development of individualized care plans to minimize these risks. The assessment should combine a focused anaesthetic history and examination with the analysis of all cardiovascular investigations, ranging from simple blood tests to complex investigations of cardiac anatomy and function. Scoring systems are often employed as a means of risk stratification and can be used not only to aid in perioperative planning and informed consent, but also as an audit tool.     

Preoperative assessment of patients for major vascular surgery

Effective preoperative evaluation of patients prior to major vascular surgery remains a significant multidisciplinary challenge. Focused preoperative evaluation targeted to organ systems can mitigate the combined effects of inherently high-risk surgical procedures undertaken in a patient population with well-recognized comorbidity. Careful history and examination, supported by appropriate investigations and specialist input, remains the cornerstone of this process, with risk increasingly quantified by dedicated scoring systems. In addition, the objective assessment of functional capacity is now common in UK units with CPET testing widely employed and considered a ‘gold standard’ by many. When employed in a timely manner, complete preoperative assessment allows more informed perioperative decision-making, frank discussion of risk with the patient and effective utilization of critical care resources if required.