Introduction
For a patient with known coronary artery disease undergoing non-cardiac surgery, the anaesthetic goal is to prevent myocardial ischemia, maintain coronary perfusion, and avoid major hemodynamic swings.
Preoperative Assessment of Patient with History of CAD
• Determine the coronary artery disease history and duration of the CAD.
• An acute MI is one that is ≤ 7 days old, while a recent MI is defined as an MI occurring more than 7 days but less than 30 days ago.
• In a patient with PCI (Percutaneous Coronary Intervention), the minimum duration of delay for non-cardiac surgery is 14 days after balloon angioplasty, 30 days after a bare-metal stent, and the optimal duration after a drug-eluting stent is 6 months to one year.
• Assess heart failure symptoms and history of previous arrhythmias.
• Exercise tolerance / functional capacity of the patient should be checked (METs score, NYHA classification).
• Review current medications, such as aspirin, oral anticoagulant treatment, beta-blockers, statins, ACE inhibitors/ARBs, and nitrates.
Management of antiplatelet therapy in the perioperative period of non-cardiac surgery is complex.
The risk of perioperative stent thrombosis is greatest in the first 4 to 6 weeks post-PCI, with excess risk that declines over time but persists up to 6 months. For most patients with chronic coronary disease, dual antiplatelet therapy is recommended for 6 months, followed by single antiplatelet therapy with either aspirin or a P2Y12 inhibitor.
Ideally, non-cardiac surgery should be postponed ≥ 1 year after PCI for acute coronary syndrome, although non-cardiac surgery can be considered ≥ 6 months after DES placement for chronic coronary disease.
Duration of Antiplatelet Therapy:
• Aspirin – minimum 4 days from drug interruption to restoration of platelet function.
• Clopidogrel – minimum 5–7 days from drug interruption to restoration of platelet function.
• Prasugrel – minimum 7–10 days from drug interruption to restoration of platelet function.
• Ticagrelor – minimum 3–5 days from drug interruption to restoration of platelet function.
• In patients on chronic statin therapy, continue the statin during the perioperative period.
• Discuss and facilitate smoking cessation, ideally 4 weeks before surgery.
• Estimate perioperative cardiac risk, including diabetes, CKD, and history of previous stroke, along with the type and urgency of surgery, expected blood loss, and surgical stress.
• Use a validated risk tool: RCRI or the NSQIP Risk Calculator.
Investigations:
• Routine blood investigations: complete blood count, renal function test, liver function test, coagulation profile (according to the type and severity of surgery and associated co-morbidities).
• ECG: to look for previous infarction, LVH, and conduction abnormalities.
• Echocardiography: consider when clinically indicated, particularly with new/worsening dyspnea, suspected heart failure, known valvular disease, or suspected significant LV dysfunction.
Optimal timing of elective or time-sensitive non-cardiac surgery after PCI
Following balloon angioplasty without coronary stent placement, elective non-cardiac surgery should be delayed for at least 14 days. After bare-metal stent placement, elective non-cardiac surgery should be delayed for more than 30 days.
After drug-eluting stent (DES) placement for acute coronary syndrome, elective non-cardiac surgery requiring interruption of one or more antiplatelet agents should ideally be delayed for at least 12 months. If the surgery is time-sensitive, it may be considered at least 3 months after DES placement when the risk of delaying surgery outweighs the risk of a perioperative major adverse cardiac event.
After DES placement for chronic coronary disease, elective non-cardiac surgery requiring interruption of one or more antiplatelet agents should reasonably be delayed for at least 6 months. Time-sensitive surgery may be considered at least 3 months after DES placement when the risk of delay outweighs the cardiac risk.
Elective non-cardiac surgery within 30 days after bare-metal stent placement or within 3 months after DES placement is potentially harmful if it requires interruption of one or more antiplatelet agents because of the risk of stent thrombosis and ischemic complications.
Antiplatelet therapy and timing of non-cardiac surgery
In selected patients with prior PCI who are on oral anticoagulant monotherapy and must stop anticoagulation, substituting aspirin may be considered until anticoagulation can safely resume (Class IIb; B-NR).
In patients with prior PCI undergoing non-cardiac surgery, continue aspirin (75–100 mg) whenever possible to reduce cardiac events (Class I; B-R). If surgery is required within 30 days of bare-metal stent placement or within 3 months of DES placement, dual antiplatelet therapy should be continued unless the bleeding risk outweighs the benefit of preventing stent thrombosis (Class I; B-NR). In selected patients at high thrombotic risk who cannot defer surgery, intravenous antiplatelet bridging may be considered within 6 months of DES placement or within 30 days of bare-metal stent placement (Class IIb; B-NR).
If surgery is time-sensitive after DES placement, it may be considered at least 3 months after PCI when the risk of postponement outweighs the risk of major adverse cardiac events (Class IIb; B-NR). Elective surgery requiring interruption of antiplatelet agents within 30 days of either bare-metal stent or DES placement is potentially harmful because of the risk of stent thrombosis and ischemic complications (Class III: Harm; B-NR).
Following balloon angioplasty without stent placement, elective non-cardiac surgery should be delayed for at least 14 days (Class I; C-LD). After drug-eluting stent (DES) placement for acute coronary syndrome, elective surgery requiring interruption of one or more antiplatelet agents should ideally be delayed for at least 12 months (Class I; B-NR). After DES placement for chronic coronary disease, delaying such surgery for at least 6 months is reasonable (Class IIa; B-NR).
For patients with coronary artery disease undergoing elective non-cardiac surgery, perioperative antiplatelet management should be decided by a multidisciplinary team, weighing bleeding risk against thrombotic risk and considering the consequences of delaying surgery (Class I; level of evidence B-NR).
Antiplatelet therapy in patients without previous PCI
In patients with coronary artery disease but no prior PCI who are undergoing elective non-carotid non-cardiac surgery, routine initiation of aspirin is not beneficial (Class III: No Benefit; B-R). P2Y12 inhibitor monotherapy may be considered when surgical bleeding risk is acceptable or aspirin is not tolerated.
Perioperative oral anticoagulant management
For patients at high thrombotic risk who must interrupt a vitamin K antagonist, preoperative bridging with parenteral heparin can be effective in reducing thromboembolism (Class IIa; C-LD). However, routine perioperative bridging is not recommended for most patients who need to interrupt oral anticoagulation because it increases bleeding risk (Class III: Harm; C-LD). After interruption, restarting oral anticoagulation is reasonable once hemostasis is achieved (Class IIa; C-LD).
For patients with cardiovascular disease receiving oral anticoagulation who require elective non-cardiac surgery, a multidisciplinary, team-based approach to the timing of interruption is recommended to balance thromboembolism against perioperative bleeding (Class I; B-NR). The timing depends on thrombotic risk, age, sex, body weight, renal clearance, surgical bleeding risk, and drug pharmacokinetics, dose, and interactions.
Perioperative renin–angiotensin–aldosterone system inhibitors
In selected patients taking chronic renin–angiotensin–aldosterone system inhibitors for hypertension, with controlled blood pressure and elevated-risk surgery, withholding these drugs 24 hours before surgery may reduce intraoperative hypotension (Class IIb; B-R). For patients taking these drugs for heart failure with reduced ejection fraction, perioperative continuation is reasonable (Class IIa; C-EO).
Perioperative beta blockers
Patients taking stable doses of beta blockers should continue them throughout the perioperative period as clinically appropriate (Class I; B-NR). If a patient scheduled for elective surgery has a new indication for beta blockade, treatment may be started sufficiently in advance, ideally more than 7 days before surgery, to assess tolerability and adjust the dose if necessary (Class IIb; B-NR). Beta blockers should not be newly initiated on the day of surgery in patients without an immediate indication because this increases postoperative mortality risk (Class III: Harm; B-R).
Choice of anaesthetic technique and agent
For non-cardiac surgery requiring general anaesthesia, either a volatile-based anaesthetic or total intravenous anaesthesia is reasonable; no apparent difference in associated cardiovascular events, including myocardial infarction and ischemia, has been demonstrated (Class IIa; A). When neuraxial anaesthesia is feasible, either neuraxial or general anaesthesia is reasonable, with no apparent difference in associated cardiovascular events (Class IIa; B-R).
Preoperative 12-lead electrocardiogram
In asymptomatic patients undergoing elevated-risk surgery without known cardiovascular disease, a preoperative resting ECG may be considered to establish a baseline (Class IIb; B-NR). Routine preoperative ECG is not recommended to improve outcomes in asymptomatic patients undergoing low-risk surgery (Class III: No Benefit; B-NR). Relevant symptoms include chest pain, dyspnea, unexplained palpitations, tachycardia, syncope, and murmurs.
In patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, other significant structural heart disease, or symptoms of cardiovascular disease who are undergoing elevated-risk surgery, a resting preoperative 12-lead ECG is reasonable to establish a baseline and guide perioperative management (Class IIa; B-NR). If a preoperative ECG shows new abnormalities, further evaluation is reasonable to refine cardiovascular risk assessment (Class IIa; B-NR).
Assessment of left ventricular function
In patients undergoing non-cardiac surgery who have new dyspnea, examination findings of heart failure, or suspected new or worsening ventricular dysfunction, preoperative assessment of left ventricular function is recommended to guide perioperative management (Class I; B-NR). For patients with known heart failure and worsening dyspnea or another change in clinical status, reassessment of left ventricular function is reasonable (Class IIa; C-LD). Routine preoperative assessment of left ventricular function is not recommended in asymptomatic, clinically stable patients because it has not shown benefit (Class III: No Benefit; B-NR).
According to the AHA 2024 guideline, do not routinely perform stress testing simply because the patient has CAD. Stress testing should be done only in selected patients with poor functional capacity and elevated perioperative risk, when the result would change management.
Anaesthesia Goals
The fundamental goal is to maintain myocardial oxygen supply and reduce myocardial oxygen demand.
• Avoid tachycardia, as it increases myocardial oxygen demand and decreases diastolic coronary perfusion time.
• Avoid hypotension, as it decreases coronary perfusion pressure and can lead to myocardial ischemia.
• Avoid hypertension → increases afterload, left ventricular wall stress, and myocardial oxygen demand.
• Anemia → low hemoglobin → decreased oxygen delivery.
The aim is to achieve:
• Optimum blood pressure and heart rate
• Adequate hemoglobin
• Adequate preload
• Adequate coronary perfusion
• Avoidance of significant sympathetic stimulation
• Maintained hemodynamic stability
• Good analgesia
• Early identification of arrhythmias
• Restart of antiplatelet therapy as soon as surgical hemostasis permits
Choice of Anaesthesia Technique
There is no single superior anaesthesia technique for coronary artery disease.
1. Important points for general anaesthesia:
• Aim for a slow and controlled induction.
• Prevent the laryngoscopy response by using adequate analgesia and maintaining an appropriate depth of anaesthesia.
• In case of hypotension, depending on the clinical situation, correct hypovolaemia and use a vasopressor when appropriate.
2. Regional / Neuraxial anaesthesia:
• May provide excellent analgesia and reduce the sympathetic response to surgery.
• However, interruption of antiplatelet therapy becomes particularly important.
Monitoring
Monitoring depends on left ventricular function, surgical risk, CAD severity, and the functional capacity of the patient.
• Standard ASA monitoring.
• Continuous ECG with appropriate ST-segment monitoring.
• Invasive arterial BP for high-risk patients/surgery.
• Central venous access when clinically indicated.
• TEE in selected high-risk patients.
Postoperative Period
The postoperative period is high risk for patients with coronary artery disease because of:
• Pain
• Tachycardia
• Hypertension / hypotension
• Hypoxia
• Anemia
• Hypercoagulability
• Increased catecholamines
Important measures are to provide good analgesia and hemodynamic stability, restart antiplatelet therapy, and provide adequate oxygenation.
The 2024 guideline specifically addresses myocardial injury after non-cardiac surgery, which is associated with increased 30-day mortality.
Reference
Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.