A heart attack is a serious event that can have lasting implications for health even if successfully managed. A recent heart attack can increase a patient’s risk for other cardiovascular events, which is relevant for surgery, including non-cardiac surgery. Some patients undergoing non-cardiac surgery face the risk of experiencing adverse cardiovascular events, including myocardial ischemia, myocardial infarction (heart attack), heart failure, arrhythmia, stroke, or cardiac death. This risk depends on various factors specific to the patient and the surgery they’re about to undergo. Identifying this increased risk can provide valuable information to patients, anesthesiologists, and surgeons, allowing them to better understand the potential benefits and risks associated with the procedure and potentially leading to interventions that can mitigate these risks. Patients with a recent heart attack (within the past 60 days), unstable angina, decompensated heart failure, severe arrhythmias, or significant valvular heart disease (especially aortic stenosis) are particularly vulnerable to perioperative cardiovascular complications.

Before surgery, it is recommended to perform a thorough evaluation, including a history and physical examination. Patients at higher risk should receive an examination that focuses on the cardiovascular system. Based on the findings from these evaluations, further tests and treatments may be necessary. Assessing the patient’s functional status is also crucial for risk assessment, as poor functional status is associated with a higher risk of complications during the perioperative period. This approach is consistent with the recommendations found in the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines on preoperative cardiovascular evaluation for non-cardiac surgery.

Electrocardiograms (ECGs) are typically obtained for patients with known cardiovascular disease, significant arrhythmias, or significant structural heart disease when they are undergoing intermediate- to high-risk surgeries. If the patient has not experienced recent cardiac symptoms and has had an ECG within the last 12 months, there is no need to repeat the test. Routine preoperative ECGs are not performed for patients undergoing low-risk surgery (with less than a 1 percent estimated risk of cardiac death or nonfatal heart attack).

Patients with cardiovascular conditions, such as those who have experienced a heart attack, are at an increased risk of experiencing cardiac complications during surgery, even if it is a non-cardiac surgery. This is mainly due to the higher incidence of significant coronary artery disease in this group, along with a greater prevalence of left ventricular systolic dysfunction in patients with cerebrovascular disease. In patients with underlying coronary artery disease, the physiological changes associated with any surgery, including shifts in volume and blood loss, heightened myocardial oxygen demand due to surgical stress, and platelet activation, may predispose them to myocardial ischemia.

For patients requiring urgent or emergency surgery and who have known or suspected coronary artery disease, heart failure, or severe valvular heart disease, it is advisable to seek prompt consultation with a cardiologist. In most cases, additional cardiovascular testing is not required, but recommendations regarding monitoring and medication management may be provided.

In rare cases, a patient may experience an acute coronary syndrome or decompensated heart failure and require urgent or emergency surgery. In these challenging clinical situations, a careful evaluation of the benefits and risks of different strategies is necessary, as there is no one-size-fits-all approach. For these patients, consulting with a cardiologist is strongly recommended.

For patients with acute coronary syndrome (ACS), elective non-cardiac surgery is typically postponed to manage the condition, including urgent revascularization and dual antiplatelet therapy. In the case of patients who have experienced a heart attack and have not undergone coronary revascularization, elective non-cardiac surgery is generally delayed for at least 60 days. When coronary revascularization is performed, the timing of elective non-cardiac surgery largely depends on assessing the risks associated with prematurely discontinuing dual antiplatelet therapy (necessary for the surgery) and the consequences of delaying the surgery, such as a decreased quality of life.

References

1. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation 2011; 124:381.

2. Liu JB, Liu Y, Cohen ME, et al. Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments. Anesthesiology 2018; 128:283.

3. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 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.

4. Palda VA, Detsky AS. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med 1997; 127:313.

5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.

6. Kristensen SD, Knuuti J. New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J 2014; 35:2344.

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