Step 1. The urgency of the surgical procedure should be assessed. In urgent cases, patient- or surgical-specific factors dictate the strategy, and do not allow further cardiac testing or treatment. In these cases, the consultant provides recommendations on perioperative medical management, surveillance for cardiac events, and continuation of chronic cardiovascular medical therapy.
Step 4. Consider the functional capacity of the patient. If an asymptomatic or cardiac-stable patient has moderate or good functional capacity, >4 METs, perioperative management is unlikely to be changed on the basis of test results irrespective of the planned surgical procedure. Even in the presence of clinical risk factors, it is appropriate to refer the patient for surgery. In patients with IHD or risk factor(s), statin therapy and a titrated low-dose β-blocker regimen can be initiated prior to surgery, as outlined in Table 11.
Step 5. It is recommended that chronic aspirin therapy be continued. Discontinuation of aspirin therapy should be considered only in those patients in which haemostasis is difficult to control during surgery.
Step 6. In patients with a moderate or poor functional capacity, consider the risk of the surgical procedure, as outlined in Table 4. Patients scheduled for intermediate-risk surgery can proceed for surgery; statin therapy and a titrated low-dose β-blocker regimen appears appropriate prior to surgery. In patients with systolic LV dysfunction, evidenced by LV ejection fraction <40%, ACE inhibitors (or ARBs in patients intolerant of ACE inhibitors) are recommended before surgery. In patients with one or more clinical risk factors, a pre-operative baseline ECG is recommended to monitor changes during the perioperative period. In patients scheduled for high-risk surgery, as described in Table 4, clinical risk factors (Table 13) are noted. In patients with up to two clinical risk factors, statin therapy and a titrated low-dose β-blocker regimen are recommended prior to surgery. In patients with systolic LV dysfunction, evidenced by LV ejection fraction, 40%, ACE inhibitors (or ARBs in patients intolerant of ACE inhibitors) are recommended before surgery.
Step 7. Interpretation of non-invasive stress test results. Patients without stress-induced ischaemia, or mild to moderate ischaemia suggestive of one- or two-vessel disease, can proceed with the planned surgical procedure. It is recommended that statin therapy and a titrated low-dose β-blocker regimen be initiated. In patients with extensive stress-induced ischaemia, as assessed by non-invasive testing, individualized perioperative management is recommended, taking into consideration the potential benefit of the proposed surgical procedure compared with the predicted adverse outcome. Also, the effect of medical therapy and/or coronary revascularization must be assessed, not only for immediate post-operative outcome, but also for long-term follow-up. In patients referred for percutaneous coronary artery intervention, the initiation and duration of antiplatelet therapy will interfere with the planned surgical procedure. In patients referred for angioplasty, non-cardiac surgery can be performed within 2 weeks after intervention with continuation of aspirin treatment. In patients with bare metal stent placement, non-cardiac surgery can be performed after 6 weeks to 3 months following intervention. Dual antiplatelet therapy should be continued for at least 6 weeks, preferably for up to 3 months. After this period, at least aspirin therapy should be continued. In patients with recent DES placement, non-cardiac surgery can be performed after 12 months following intervention, before which time dual antiplatelet therapy is recommended. After this period, at least aspirin therapy should be continued.
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