Risk Assessment Before Noncardiac Surgery

Abstract Perioperative risk assessment is essential in screening patients before noncardiac surgery. Cardiovascular complications such as fatal and non-fatal myocardial infarction (MI), ventricular arrhythmia, pulmonary edema, and stroke are important in-hospital causes of morbidity and mortality intra and post-operatively. The optimal approach is to identify patients at increased risk so that appropriate testing and therapeutic interventions are undertaken a priori to minimize such risk. The initial preoperative evaluation includes identification of surgery-specific risk, patient exercise functional capacity and clinical risk profile. Patients with major predictors of events such as acute coronary syndromes, recent MI, unstable arrhythmia, and severe valvular disease warrant further management and optimization that often lead to delaying surgery. Those with three or more predictors (history of ischemic heart disease, compensated heart failure, diabetes, renal insufficiency, or history of cerebrovascular disease) undergoing high- risk surgery often require stress testing. Although data from randomized prospective trials are lacking, numerous studies have demonstrated the utility of myocardial perfusion imaging (MPI) for determination of perioperative cardiac risk. The goal of this chapter is to review the use of MPI for preoperative risk assessment and the recommendations from the current guidelines. The focus will be on short-term and long-term prognosis including special groups such as after coronary stenting and before vascular surgery, liver and renal transplantation.