Rapid Review·Cardiovascular
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HY Approach
T1Must knowApproach to Perioperative Cardiac Management
Focus on
Three perioperative problems with their own logic: valve disease (fix a symptomatic severe stenosis first, otherwise proceed with monitoring), anticoagulation (hold by drug and kidney, do not bridge routine AF, bridge only mechanical mitral valves and very recent thrombosis), and atrial fibrillation around surgery (cardiovert if unstable, treat triggers and control rate if not, and do not forget the stroke-risk decision).
Key takeaways
Three groups need a specific plan
Beyond risk stratification
after the sequence on Approach to Preoperative Cardiac Evaluation, three groups need their own plan.- Patients with valve disease, patients on antithrombotic therapy, and patients with atrial fibrillation.
Valve disease before non-cardiac surgery
Echo first
every patient with a murmur or known valve disease without an echocardiogram in the past year, or with new symptoms, gets echocardiography first.- Then the Perioperative valve pathway.
| Valve status | Plan |
|---|---|
| Mild disease | Proceed |
| Moderate to severe and symptomatic (or meets intervention criteria on its own) | Valve intervention first (aortic replacement for stenosis, repair for mitral regurgitation, balloon valvotomy for mitral stenosis), then the surgery |
| Moderate to severe, asymptomatic, low-risk surgery | Proceed |
| Moderate to severe, asymptomatic, higher-risk surgery, normal ejection fraction and no pulmonary hypertension | Proceed with invasive hemodynamic monitoring and lesion-aware anesthesia |
| Moderate to severe, asymptomatic, higher-risk surgery, reduced ejection fraction or pulmonary hypertension | Valve intervention first |
Aortic stenosis anesthesia
avoid hypotension and tachycardia, keep preload and sinus rhythm, cautious with vasodilators and neuraxial blocks.Mitral stenosis anesthesia
avoid tachycardia and fluid overload.Regurgitant lesions
avoid bradycardia and high afterload.Prosthetic valves
the anticoagulation plan below (Prosthetic Heart Valves).Perioperative anticoagulation
Four variables
the drug and its clearance, the procedure's bleeding risk, the thromboembolic indication, and renal function, combined on the Perioperative anticoagulation pathway.Minimal-bleeding procedures (dental extraction, cataract, skin biopsy, many pacemakers)
continue anticoagulation with local hemostasis.Warfarin
stop 5 days before (international normalized ratio (INR) under 1.5; check the day before, vitamin K if still high), resume 12 to 24 hours after hemostasis.Direct oral anticoagulants
hold 1 to 2 days for low-bleeding-risk and 2 to 3 days for high-bleeding-risk procedures.- Longer for dabigatran and with a creatinine clearance under 50; resume 24 to 72 hours after; no bridging.
Heparin bridging is not routine
in atrial fibrillation it adds bleeding without preventing thromboembolism.Antiplatelets
aspirin usually continued (stents, recent acute coronary syndrome); P2Y12 inhibitors held 5 to 7 days unless a recent stent forbids it (Acute Coronary Syndrome); neurosurgery holds everything.Atrial fibrillation around surgery
Pre-existing
continue rate control (never withdraw the beta blocker abruptly), interrupt anticoagulation as above, check electrolytes and thyroid function, target a resting rate under 110.New or rapid atrial fibrillation, unstable
per the Preoperative atrial fibrillation pathway, hypotension, ischemia or heart failure means synchronized cardioversion.New or rapid atrial fibrillation, stable
correct the triggers (pain, hypovolemia, hypoxia, electrolytes, infection, anemia, withdrawal, thyrotoxicosis) and rate control.- Intravenous beta blocker or diltiazem; amiodarone if the ejection fraction is low; then defer elective surgery until controlled.
Post-operative atrial fibrillation
days 2 to 4 after thoracic or cardiac surgery; rate control, anticoagulate if it persists over 48 hours and bleeding allows.Other perioperative issues
Pacemakers and defibrillators
interrogation within 6 to 12 months; electrocautery can inhibit pacing or trigger shocks.- Use bipolar cautery, a magnet over the defibrillator to suspend therapies (it does not affect pacing), asynchronous pacing in dependent patients, an external defibrillator ready (Cardiac Implantable Devices).
Heart failure
optimize volume, continue guideline therapy (hold the sodium-glucose cotransporter-2 inhibitor 3 to 4 days).Pulmonary hypertension
high risk; continue vasodilators, avoid hypoxia, hypercapnia and acidosis.Hypertension
proceed if under 180/110, defer elective surgery above that.A patient in atrial fibrillation on apixaban, with no stroke in the past year, needs an elective colectomy (high bleeding risk); creatinine clearance is normal. How long is apixaban held, and should he be bridged with heparin?
Hold the direct oral anticoagulant 2 to 3 days (high bleeding risk), resume 24 to 72 hours after, and no bridging: bridging is only for the very-high-risk (mechanical mitral valve, atrial fibrillation with a stroke in the past 3 months, recent venous thromboembolism, ventricular thrombus).
How it's tested
A 74-year-old with a loud ejection murmur, exertional dyspnea and a severe aortic stenosis on echo, scheduled for elective hip replacement: symptomatic severe AS — valve intervention (TAVR/SAVR) first, then the hip.
Same valve, no symptoms, normal EF, planned low-risk cataract surgery: proceed.
AF patient (CHA2DS2-VASc 3) on apixaban with a colonoscopy and polypectomy planned: hold apixaban 2 days before (longer if CrCl < 50), no heparin bridging, resume 24–48 h after.
Mechanical mitral valve on warfarin needs a laparotomy: stop warfarin 5 days before and bridge with LMWH or IV heparin — this is the high-risk exception.
Pre-op clinic finds new AF at 140 with BP 80/50 and chest pain: synchronized cardioversion; the elective operation waits.
A dialysis patient on dabigatran before a high-bleeding-risk operation: hold for at least 4 days — impaired renal clearance prolongs the interruption; a single fixed interval is wrong.
Go deeper
Guidelines: 2024 AHA/ACC Perioperative Cardiovascular Management Guideline · CHEST Perioperative Management of Antithrombotic Therapy
Related Step 2 pages: Approach to Preoperative Cardiac Evaluation, Prosthetic Heart Valves, Aortic Stenosis, Atrial Fibrillation, Acute Coronary Syndrome, Cardiac Implantable Devices, Anticoagulants & Antiplatelets
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