Preoperative Cardiac Risk Assessment for Noncardiac Surgery: Defining Costs and Risks

Cardiac risk stratification before noncardiac surgery remains important. Two major areas have been emphasized, namely, cost-effective risk stratification and enhanced identification of high-risk populations. Recent studies have highlighted the lack of quality and affordable medical consultation. The indications for resting preoperative echocardiography merit streamlining, given recent data that failed to demonstrate tangible benefit. Furthermore, noninvasive cardiac stress testing is expensive and unnecessary in low-risk patients. Perioperative troponin determination significantly improves the detection of myocardial infarction, facilitating its early management. The revised cardiac risk index is a standard tool for risk stratification, despite multiple limitations. The first approach has been to recalibrate the traditional risk index to specific high-risk surgical subgroups. The second approach has been to develop new cardiac risk models with more power. Both approaches have yielded risk calculators that outperform the traditional risk model. Furthermore, this latest generation of risk models is available as online calculators that can be accessed at the bedside. Further clinical trials are indicated to test the validity, clinical utility, and cost-effectiveness of these novel risk calculators. It is likely that these powerful instruments will refine the indications for specialized cardiac testing, offering multiple opportunities to reduce perioperative risk and cost simultaneously. (C) 2013 Published by Elsevier Inc.