Risk reduction strategies: coronary revascularization before non-cardiac surgery

An individualized, stepwise patient evaluation based on the degree of urgency of non-cardiac surgery, functional capacity, clinical presentation, and estimated cardiovascular stress related to surgery is recommended in order to assess the perioperative cardiovascular risk and optimize management. Myocardial ischaemia in the context of non-cardiac surgery may be related to acute coronary syndromes secondary to coronary plaque rupture or prolonged myocardial oxygen supply–demand imbalance. Randomized controlled trials have failed to show a benefit of routine preoperative prophylactic myocardial revascularization. Preoperative coronary angiography and, if appropriate, myocardial revascularization may be considered before high-risk surgery depending on symptom status and extent of ischaemia on non-invasive imaging. In patients requiring percutaneous coronary intervention, guidelines recommend new-generation drug-eluting stents over bare-metal stents, though randomized data are absent. While the minimal delay for a safe surgery following drug-eluting stent implantation remains to be defined, a time window of 5–6 weeks between percutaneous coronary intervention and surgery appears to be adequate in patients who cannot wait longer.