Patient undergoing non-cardiac surgery represents an opportunity to assess cardiac risk both in the short and long term. A full evaluation should be performed to understand prognosis and any need for treatment of underlying cardiac conditions or risks. The referring physician should be informed of the evaluation results and their implications. Patients should not be described as simply "cleared for surgery".

1. non cardiac surgery represent pt first opportunity to receive appropriate
assessment for both short term and long term cardiac risk
thus this is the ideal opportunity to effect the long term treatment of pt with
significant cardiac disease or risk of such disease.
thus the referring phycisian should be inform the result of evaluation and
implication of pt prognosis
should not use the phrase " clear for surgery'

2. ability to perform activities of daily living.
express aerobic demands for specific activities.

3. Activities that require more than 4 METs include moderate cycling, climbing hills,
ice skating, roller blading, skiing, singles tennis, and jogging

4. Patient should undergo evaluation and treatment before non cardiac surgery

5. 9 indipendant risk factors evaluated on a point scale

6. In patients without documented CAD, surveillance should be restricted to those
patients who develop perioperative signs of cardiovascular dysfunction.

7. Some procedures may be short, with minimal fluid shifts, whereas others may be
associated with prolonged duration, large fluid shifts, and greater potential for
postoperative myocardial ischemia and respiratory depression.

8. vascular surgery --> clinicians should incorporate the similarly poor long-term
survival rates that accompany these procedures into their decision-making
processes.
intermediate-risk category --> morbidity and mortality vary depending on the
surgical location and extent of the procedure.

9. In many instances, patient- or surgery- specific factors dictate an obvious strategy
(eg, emergency surgery) that may not allow for further cardiac assessment or
treatment.
Step 3: Is the patient undergoing low-risk surgery? Many procedures are
associated with a combined morbidity and mortality rate less than 1% (see Section
4), even in high-risk patients.
Interventions based on cardiovascular testing in stable patients would rarely result
in a change in management, and it would be appropriate to proceed with the
planned surgical procedure

10. Step 4: Does the patient have a functional capacity greater than or equal to 4 METs without
symptoms? Functional status has been shown to be reliable for perioperative and long-term
prediction of cardiac events
In highly functional asymptomatic patients, management will rarely be changed based on the results
of any further cardiovascular testing. It is therefore appropriate to proceed with the planned surgery.
In patients with known cardiovascular disease or at least 1 clinical risk factor, perioperative heart
rate control with beta blockade appears appropriate as outlined in Section 7.2.
Step 5: If the patient has poor functional capacity, is symptomatic, or has unknown functional
capacity, then the presence of clinical risk factors will determine the need for further evaluation.

11. active vs sedentary lifestyle
active , asymptomatic, run for 3 mins- may need no further evaluation
sedentary, asymptomatic, but with clinical risk factor -- more extensive
preoperative evaluation

12. In general, indications for further cardiac testing and treatments are the same as in
the nonoperative setting
The use of both noninvasive and invasive preoperative testing should be limited to
those circumstances in which the results of such tests will clearly affect patient
management.

13. routine coronary revascularization in pt with stable cardiac symptoms before major
vascular surgery -- does not alter the long term outcome and short term risk of
death/ MI

14. Clarification of these questions is an important goal of the preoperative history and
physical examination, and selected noninvasive testing is used
to determine the patient’s prognostic gradient of ischemic response
during stress testing.

15. delay surgery to optimize effect of anti HPT

16. which can increase the volume of regurgitation by increasing the duration of
diastole.
Tachycardia thus reduces the time of regurgitation in severe aortic regurgitation

17. Prevention of Bacterial Endocarditis, Recommendations by the American Heart
Association, JAMA, 11 June 1997; 277: 1794-1801

18. unschedule non cardiac surgery in a pt who has undergone a prior PCI present
special challenges with regards of management of dual antiplatelets agents
required.

19. unschedule non cardiac surgery in a pt who has undergone a prior PCI present
special challenges with regards of management of dual antiplatelets agents
required.

20. risk of bare-metal stent thrombosis diminishes after endothelialization of the stent
has occurred (which generally takes 4 to 6 weeks), it appears reasonable to delay
elective noncardiac surgery for 4 to 6 weeks to allow for at least partial
endothelialization of the stent, but not for more than 12 weeks, when restenosis
may begin to occur risk of bare-metal stent thrombosis diminishes after
endothelialization of the stent has occurred (which generally takes 4 to 6 weeks), it
appears reasonable to delay elective noncardiac surgery for 4 to 6 weeks to allow
for at least partial endothelialization of the stent, but not for more than 12 weeks,
when restenosis may begin to occur..

21. because of concerns about late-stent thrombosis.

22. The thienopyridines and aspirin inhibit platelet aggregation and reduce stent
thrombosis but increase the risk of bleeding.

23. Significant surgical procedures include major
abdominal or thoracic surgery, particularly when
the surgery involves large amounts of
electrocautery.

24. the availability of expertise in pacing and/or ICDs

25. The electrical current generated

26. Efforts should be made to minimize the chance
for interactions by

27. Therefore, a discussion of these issues before the planned surgery will allow for a
smooth transition through the perioperative period.