Rapid Clinical Updates: The Latest Hot Topics in Perioperative Medicine-Handout

Handout

Pdf Summary

This summary provides rapid clinical updates on perioperative cardiac risk assessment and management, particularly in an aging surgical population with common cardiac complications.<br /><br />Key Context:<br />- Although coronary artery disease (CAD) remains important, other cardiac conditions like congestive heart failure (CHF), pulmonary hypertension (PH), and valvular disease often contribute more significantly to perioperative risk.<br />- Current AHA/ACC guidelines offer new evaluation strategies for higher-risk patients, emphasizing less reliance on stress testing and more on biomarkers.<br /><br />Stepwise Approach:<br />1. Determine surgical urgency.<br />2. Identify cardiovascular “red flags” warranting reassessment: new/worsening cardiac symptoms, decompensated HF, severe valvular disease, severe hypertension (SBP ≥180 or DBP ≥110), pulmonary hypertension, uncontrolled arrhythmias, recent stroke (within 3 months), recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI).<br />3. Assess cardiac diseases beyond CAD, focusing on CHF, PH, and valvular disease as key perioperative mortality drivers.<br />4. Cardiac testing should prioritize biomarkers (pro-BNP, NT-proBNP, high-sensitivity troponin) with suggested cutoffs (BNP 92 ng/L, NT-proBNP 300 ng/L, hs-troponin 99th percentile) to avoid unnecessary expensive imaging.<br /><br />Imaging recommendations:<br />- Echocardiography is indicated for new/worsening HF symptoms, suspected moderate/severe valvular disease, severe PH, RV dysfunction, or unexplained dyspnea.<br />- Echocardiography is not recommended for stable, asymptomatic HF, low-risk surgeries, advanced age alone, or cases where results will not change management.<br />- Stress testing and coronary CT angiography (CCTA) should be reserved for patients with elevated risk surgery, poor or unknown functional capacity, and elevated calculated cardiac risk.<br /><br />Postoperative Myocardial Injury (MINS):<br />- Defined by troponin rise/fall above the 99th percentile within 30 days post-op and associated with high mortality.<br />- Non-ischemic causes such as anemia, sepsis, pulmonary embolism, and acute kidney injury must be excluded.<br />- Recommended to measure troponin at 24 and 48 hours post-surgery in patients ≥65 years with cardiovascular risk factors or known CV disease/symptoms.<br />- Elevated troponin management includes echocardiography, possible stress testing, coronary imaging if meeting MI criteria, and intensifying guideline-directed medical therapy including aspirin and statin.<br /><br />References:<br />- Thompson et al., Smilowitz et al.<br />- Last updated January 2026.

Keywords

perioperative cardiac risk

coronary artery disease

congestive heart failure

pulmonary hypertension

valvular disease

AHA/ACC guidelines

biomarkers

echocardiography

postoperative myocardial injury

troponin monitoring