Assessing and addressing cardiac fitness for radical lung cancer surgery
| Issue | Recommendations and evidence | [Ref.] | |
| Estimating pre-operative cardiac risk | |||
| Summary recommendation | Patients should be risk stratified using validated risk indexes, which should direct any additional testing (recommendation grade B, evidence level 2++). | 2–4 | |
| Noninvasive stress tests | Patients with 1) poor functional status (<4 METs) and 1–2 RCRI criteria, and 2) a history of angina or claudication should be generally appropriate for noninvasive testing to assess risks for surgery (recommendation grade B, evidence level 2++). Patients at >20% risk according to initial estimates (RCRI >3) may still have high peri-operative risks, despite a negative noninvasive study (>5% post-test probability with negative test) (recommendation grade B, evidence level 2++). | 5–8 | |
| However, treatment strategies based on the results of non-invasive testing are not of proven value. | 9 | ||
| Identifying patients with aortic stenosis | Patients with physical findings consistent with aortic outflow tract obstruction should have pre-operative echocardiography (recommendation grade B, evidence level 2++). | 10–12 | |
| Echocardiography | Pre-operative echocardiography should also be obtained when other valvular disease, left ventrical dysfunction, or pulmonary hypertension is suspected, according to published guidelines (recommendation grade B, evidence level 2++). | 13 | |
| Cardiological approaches for reducing risks | |||
| Patients with hypertension | Anti-hypertensive medications should be given up to the morning of surgery and be continued orally or intravenously as soon as possible post-operatively (recommendation grade D, evidence level 4). | 14 | |
| Patients with pulmonary hypertension or congenital heart disease | Beneficial chronic therapies could be generally recommended during the peri-operative period (recommendation grade D, evidence level 4). | 15, 16 | |
| Patients with hypertrophic cardiomyopathy | Management could be similar to the chronic setting (recommendation grade D, evidence level 4). | 17 | |
| Patients with heart failure or arrhythmias | Elective surgery could be delayed if heart failure or arrhythmias are unstable, meet accepted criteria for new interventions, or are likely to represent inadequately treated ischaemic heart disease. Optimal management of patients with stable heart failure or adequately treated arrhythmias could adhere to published guidelines (recommendation grade D, evidence level 4). | 5, 6 | |
| Pulmonary artery catheterisation | Few, if any, noncardiac surgery patients must receive routine pulmonary artery catheterisation (recommendation grade A, evidence level 1++). | 18 | |
| Peri-operative beta blockade | Patients with ischaemic heart disease generally do not benefit from newly prescribed peri-operative beta blockade (recommendation grade A, evidence level 1++), but beta blockers should be continued in patients who are already taking them (recommendation grade B, evidence level 2++) and may be beneficial as new therapy in very high-risk patients (recommendation grade B, evidence level 1). | 19–23 | |
| Peri-operative α-adrenergic modulation | Modulation of the α-adrenergic systems with drugs such as clonidine may be beneficial for vascular surgery but are of even less certain benefit for other operations (recommendation grade A, evidence level 1+). | 24–26 | |
| Other anti-ischaemic medications | Prophylactic nitrates can reduce ischaemia but not major events; prophylactic calcium channel blockers could be of uncertain benefit (recommendation grade B, evidence level 2++). | 25–27 | |
| Peri-operative use of HMG-CoA reductase inhibitors (statins) | Statin lipid-lowering agents could be started before noncardiac surgery whenever long-term lipid-lowering therapy is indicated (recommendation grade D, evidence level 4). | 28, 29 | |
| Peri-operative coronary revascularisation | Patients at high risk clinically or based on noninvasive testing must be considered for diagnostic catheterisation. Coronary revascularisation must be recommended only for patients who would benefit in the absence of the planned surgery (recommendation grade A, evidence level 1++). | 30 |
METs: metabolic equivalents; RCRI: revised cardiac risk index; HMG-CoA: 3-hydroxy-3-methyl-glutaryl coenzyme A.