Detailed charts outlining the individual guideline recommendations are available as an Tielsch J, The decision regarding stent type needed to balance long-term efficacy with safety, in particular the risk of stent thrombosis with early discontinuation of dual antiplatelet therapy (DAPT) that would be required for esophageal surgery. The guidelines suggest that preoperative random glucose measurement could be considered in patients at very high risk of undiagnosed diabetes on the basis of history, examination, or use of certain medications (e.g., glucocorticoids), and in patients with signs or symptoms of undiagnosed diabetes. Â Â Â Â Â Print, Suggested algorithm for performing preoperative electrocardiography. / AMINAH JATOI, MD, is a professor of oncology and a consultant in the Division of Medical Oncology at the Mayo Clinic. online appendix . http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RoutineAdmissionAndPreoperativeChestRadiography.pdf. The RCRI consis… This content is owned by the AAFP. Joo HS, ; Sanon S, Rihal CS. The majority of literature on perioperative stroke focuses on cardiac surgery, with an event rate ranging from 2% to 10% according to the type of operation. If a patient has ACS and has known urgent noncardiac surgery in the near future, as seen in the case presented, it is reasonable to use BMS with early discontinuation of DAPT. This guideline is aimed primarily at practitioners within the UK. 4 hours) 1 Ischemic heart disease 1 History of congestive heart failure 1 History of cerebrovascular disease 1 Insulin therapy for diabetes 1 Perioperative serum creatinine . The present Guidelines focus on the cardiovascular management of patients in whom heart disease is a potential source of complications during non-cardiac surgery. Both first-generation DES and second-generation DES were used. ; They should be … Savoldelli GL. Patients in their usual state of health who are undergoing cataract surgery do not require preoperative testing. Patients should have preoperative ECG before undergoing a high-risk procedure. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery. They provide a framework for considering cardiac risk of noncardiac surgery in a variety of patient and surgical situations. 2008;140(5):496–504. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. Surgical cardiac risk is considered low if the risk of a perioperative cardiac event is less than 1 percent, intermediate if 1 to 5 percent, and high if greater than 5 percent 4,7Â (Table 14). 15 Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Greaves M; Identification of increased risk provides the patient (and surgeon) with information that helps them better understand the benefit-to-risk ratio of Current guidelines recommend delaying noncardiac surgery if possible based on stent type chosen during PCI. Daley J, ACR Appropriateness Criteria: routine admission and preoperative chest radiography. Other history includes w… Armstrong EJ, Graham L, Waldo SW, Valle JA, Maddox TM, Hawn MT. Cataract surgery is addressed separately because it is an area with excellent evidence-based data to drive decision making about preoperative testing. The ERC guidelines ask clinicians to consider the following as causes of the arrest: hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, tension pneumothorax, thrombo-embolism, tamponade and toxins, the so-called four ‘H’s and four ‘T’s. A total of 4303 patients were compared with a control group (n=20,232) without previous ischemic heart disease who underwent similar surgical procedures. Preoperative tests: the use of routine preoperative tests for elective surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery [published corrections appear in. Graham et al. Data Sources: A search of PubMed and Scopus was performed using the key terms preoperative, perioperative, guidelines, and preoperative test. ; Creatinine level > 2.0 mg per dL (176.80 μmol per L), Suprainguinal vascular surgery, intrathoracic surgery, or intra-abdominal surgery, Â Â Enlarge 1. 2008;52(9):793–794]. revealed no higher adverse events following DES implantation for 30-day postsurgical outcomes.7 In a study by Egholm et al., the comparison was made between patients treated with DES and patients with no ischemic heart disease who both required noncardiac surgery. Biopsies were consistent with esophageal adenocarcinoma. Perspective: There are important updates to the 2014 ESC/ESA Guidelines on Non-cardiac Surgery, with some notable differences compared to the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery. Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery. ; An oncology evaluation indicated that this was a second primary malignancy. Â Â Enlarge Med Clin North Am. Mangels DR, Nathan A, Tuteja S, Giri J, Kobayashi T. Contemporary Antiplatelet Pharmacotherapy in the Management of Acute Coronary Syndromes. et al. N Engl J Med. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. 2008;52(9):793–794]. Historically, testing before noncardiac surgery involved a battery of standard tests applied to all patients (e.g., chest radiography, electrocardiography [ECG], laboratory testing, urinalysis). et al. 2003;87(1):7–40. Interestingly, the risk difference was the same if surgery was delayed at least 1 month after PCI.8, Patients who have PCI and then require urgent noncardiac surgery also need careful management of DAPT, which is the next clinical challenge to our case. Accessed December 12, 2012. Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, CardioSource Plus for Institutions and Practices, Nuclear Cardiology and Cardiac CT Meeting on Demand, Annual Scientific Session and Related Events, ACC Quality Improvement for Institutions Program, National Cardiovascular Data Registry (NCDR). The National Veterans Administration Surgical Quality Improvement Program. The value of routine preoperative medical testing before cataract surgery. Minimize use of critical supplies and equipment that can be redirected to care for more acute patients and for the care of COVID-19 patients.The conservation of PPE and other equipment is critical. Several groups provide guidance on preoperative coagulation testing, and concur that indiscriminate preoperative coagulation testing is not warranted.2,3,8,9 As with CBC testing, the consensus is that coagulation testing be reserved for patients with medical conditions associated with impaired hemostasis (e.g., liver disease, diseases of hematopoiesis), patients taking anticoagulants, and those whose history or examination findings suggest an underlying coagulation disorder (e.g., history of spontaneous bruising or excessive surgical bleeding, family history of a known heritable coagulopathy). For information about the SORT evidence rating system, go to, Source: Fleisher LA, Beckman JA, Brown KA, et al. American College of Radiology. Because the plan was to perform surgical resection as soon as possible, the patient underwent PCI with BMS (Figure 3). Study of Medical Testing for Cataract Surgery. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. This balance of ischemic benefit and bleeding risk is a common clinical challenge seen in ACS patients and can be particularly vexing when a patient with recent ACS and/or PCI requires noncardiac surgery.2, The incidence of noncardiac surgery after undergoing PCI, as seen in our case, is roughly 5-10%.3 This poses a difficult scenario for the clinician when an ACS/PCI patient requires urgent noncardiac surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery [published corrections appear in J Am Coll Cardiol. Brown KA, She is also a staff physician at the Mayo Clinic's Preoperative Evaluation Center, and the founder and codirector of the Mayo Clinic's Overview of Perioperative Medicine course. Risk Associated With Surgery Within 12 Months After Coronary Drug-Eluting Stent Implantation. Routine preoperative testing: a systematic review of the evidence. Prior to treatment, which included surgical resection, chemotherapy, and radiation therapy, it was recommended that the patient undergo coronary angiography to define the burden of coronary artery disease (CAD). Marcantonio ER, Watson HG, Chee YL, Instead, the consensus is to recommend testing for select patients based on conditions that would increase the pretest probability of diagnosing anemia (e.g., a chronic inflammatory condition, chronic kidney disease, chronic liver disease, clinical signs or symptoms of anemia) or procedures in which significant blood loss is anticipated. Circulation. Schulman-Marcus J, Pashun RA, Feldman DN, Swaminathan RV. J Am Coll Cardiol. The value of routine preoperative medical testing before cataract surgery. ; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. High-risk surgery (e.g., emergency surgery, major thoracic procedures, cardiac procedures, aortic/major vascular procedures, procedures . Ultimately, the decision on length of DAPT and type of coronary intervention is best made on an individualized basis. Worldwide 1 in every 30-40 adults has major noncardiac surgery (ie, defined in this report as surgery requiring overnight hospital admission) annually, 1 and > 10 million of the > 200,000,000 patients having surgery will suffer a major cardiac complication (ie, cardiac death, myocardial infarction/injury, cardiac arrest) in the first 30 days after surgery. Previous: Does Screening Mammography Lead to Overdiagnosis of Invasive Breast Cancer? Beckman JA, Eur Heart J. For this reason, DAPT with aspirin and P2Y12 receptor antagonists is foundational for the management of ACS. Chest radiography is reasonable for patients at risk of postoperative pulmonary complications if the results would change perioperative management. et al. However, the prevalence of inherited coagulopathies is low, and in patients with the most common disorder (von Willebrand disease), results of routine coagulation tests may be normal. Author disclosure: No relevant financial affiliations. Coagulation studies are reserved for patients with a history of bleeding or medical conditions that predispose them to bleeding, and for those taking anticoagulants. / afp A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. © 2020 American College of Cardiology Foundation. More recent practice guidelines continue to recommend testing in select patients guided by a perioperative risk assessment based on pertinent clinical history and examination findings, although this recommendation is based primarily on expert opinion or low-level evidence.2–9 Many of the recommendations include wording such as “consider testing if ” or “testing may be reasonable.” Recommendations are not always user-friendly. There is consensus among the guidelines that patients with active cardiovascular signs or symptoms should undergo ECG. Electrocardiography is recommended for patients undergoing high-risk surgery and those undergoing intermediate-risk surgery who have additional risk factors. He is also a staff physician at the Mayo Clinic's Preoperative Evaluation Center. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. The National Veterans Administration Surgical Quality Improvement Program. He is also a staff physician in the Mayo Clinic's Thrombophilia Clinic. A preoperative complete blood count is indicated for patients at risk of anemia based on their history and physical examination findings, and those in whom significant perioperative blood loss is anticipated. British Committee for Standards in Haematology. Snow V, Naik VN, The patient remained chest-pain free with no further angina or melena 2 days after PCI and was discharged home with a plan to pursue surgical resection of his esophageal malignancy after completion of his course of DAPT. European Society of Anaesthesiology assembled 'Guidelines on non-cardiac surgery: cardiovascular assessment and management'. 8. 2000;232(2):242–253. In non-cardiac surgical patients, non-VF/VT arrests are associated with a poorer outcome. Routine preoperative testing: a systematic review of the evidence. 28 Several randomized clinical trials have demonstrated, however, that nonalcoholic clear fluids can be safely given up to 2 hours before the induction of anesthesia, and a light meal can … The goal of preoperative evaluation is to identify and optimize conditions that increase perioperative morbidity and mortality. In addition, invasive risk stratification with coronary angiography and revascularization for high-risk patients reduces long-term morbidity and mortality. Beta-blocker therapy was held due to bradycardia. Graham MM, Sessler DI, Parlow JL, et al. ESAYAS B. KEBEDE, MD, is a senior associate consultant in the Division of General Internal Medicine at the Mayo Clinic. References. Khuri SF; The patient history is important in determining cardiac or comorbid diseases that would put the patient at high surgical risk. Arozullah AM, However, at a minimum, if the surgeon orders a type and cross (as opposed to a type and screen) in preparation for a procedure, it is likely that significant blood loss is anticipated. For BMS, current recommendations are delaying surgery for at least 4-6 weeks; for DES, the delay is thought to be between 6 and 12 months.4 This time frame is derived from the difference in time to stent endothelialization, which can affect the risk of stent thrombosis.5, BMS was reportedly used more frequently in patients with planned noncardiac surgery at the time of PCI. Abstract. Cardiac complications are common after major non‐cardiac surgery. In this case, baseline hemoglobin and hematocrit measurements can help assess the blood loss and inform the need for transfusion. Next: Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors, Home Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery. Booth A, These investigations can be helpful to stratify risk, direct anesthetic choices, and guide postoperative management, but often are obtained because of protocol rather than medical necessity. Mangione CM, Due to the gastrointestinal bleeding and anemia, P2Y12 inhibition and antithrombin therapy was withheld. 11. Bass EB, The patient's hemoglobin was 8.3 g/dL, significantly decreased from his baseline of 12 g/dL 3 months prior to presentation. Our case underscores the need for more evidence regarding safest management of patients with ACS and those undergoing PCI needing urgent noncardiac surgery. et al. Primary care physicians are in an ideal position to take an active role in the multidisciplinary, system-based approach to defining preoperative testing standards for their own institutions to provide high-quality, cost-effective health care. Warshauer J, Patel VG, Christopoulos G, Kotsia AP, Banerjee S, Brilakis ES. Bloomington, Minn.: Institute for Clinical Systems Improvement; 2012. A complete blood count is indicated for patients with diseases that increase the risk of anemia or patients in whom significant perioperative blood loss is anticipated. Address correspondence to Molly A. Feely, MD, Mayo Clinic, 200 First St. SW, Rochester, MN 55905 (e-mail: email@example.com). Chee YL, Invasive Cardiovascular Angiography and Intervention. 2007;50(17):e159–e241. ; As such, current guidelines primarily utilize the clinical risk factors from the RCRI but not the procedural risk factor. Can J Anaesth. On arrival, the troponin I was 0.24 ng/mL (upper limit of normal 0.04 ng/mL). ECG is recommended before intermediate-risk procedures in patients with at least one clinical risk factor identified by the RCRI; those with two or more clinical risk factors are at significantly higher risk of a major cardiac event. In a study by Holcomb et al. Routine preoperative medical testing for cataract surgery Cochrane Database Syst Rev. 2007;297(22):2481–2488. The most widely accepted guideline in the United States advocates against ECG in patients undergoing low-risk surgery.4 The dilemma arises in how to define low perioperative cardiac risk, and what to do for patients who do not have active cardiovascular symptoms and who are not undergoing low-risk surgery. The value of screening preoperative chest x-rays: a systematic review. ACR Appropriateness Criteria: routine admission and preoperative chest radiography. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. Patients who require non-cardiac surgery in acute coronary syndrome. Also searched were the Cochrane Database of Systematic Reviews, the U.S. Preventive Services Task Force, National Guideline Clearinghouse, Institute for Clinical Systems Improvement, Physicians' Information and Education Resource (American College of Physicians' PIER), and the Agency for Healthcare Research and Quality evidence reports. American College of Radiology. 10th ed. Bax JJ, Don't miss a single issue. Health care guideline: pre-operative evaluation. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. ECG is not needed in patients undergoing low-risk procedures (Figure 1). CAD is one of the most prevalent diseases in the country and a leading cause of mortality. Most CS programs mandate that a patient ingest nothing by mouth after midnight for surgery the following day, or at the very least, fast for 6 to 8 hours from the intake of a solid meal before elective cardiac surgery. An important risk of DAPT is bleeding, which can occur both acutely and during long-term therapy. 2009;30(22):2769–2812. 3. Reducing the rate at which we utilize these supplies will help ensure they are available for critical use. Practice advisory for preanesthesia evaluation. After discussion of risks and benefits, patient underwent percutaneous coronary intervention (PCI) of the diseased vessels. Qaseem A, MOLLY A. FEELY, MD; C. SCOTT COLLINS, MD; PAUL R. DANIELS, MD; ESAYAS B. KEBEDE, MD; AMINAH JATOI, MD; and KAREN F. MAUCK, MD, MSc, Mayo Clinic, Rochester, Minnesota. None of the guidelines recommend indiscriminate preoperative CBC or hemoglobin testing. Mangione CM, Schein O. British Committee for Standards in Haematology. 16. Fleisher LA, 15. Noncardiac surgeries performed in patients with a recent myocardial infarction or stent implantation have been associated with increased risk of perioperative cardiac events, stent thrombosis, and bleeding compared with patients with more distant myocardial infarction or stent implantation. Patients with acute coronary syndrome (ACS) benefit from potent antithrombotic therapy and, for those with high-risk clinical features, early invasive risk stratification. Random glucose testing should be performed in patients at high risk of undiagnosed diabetes mellitus. Preoperative electrolyte and creatinine testing should be reserved for patients at risk of electrolyte abnormalities or renal impairment. Â Wessler JD, Kirtane AJ. Anesthesiology. Case series have shown that abnormalities were observed in up to 34 percent of patients, but these results led to a change in management less than 14 percent of the time, and of those patients, less than 1 percent had postoperative complications.8 Two guidelines reviewed evidence based on case series and expert opinion.3,8 There is little evidence that an abnormal result is associated with postoperative complications,1 and predictive values of routine urinalysis in asymptomatic patients are poor.13 Guideline consensus on the basis of expert opinion is that routine urinalysis is not recommended in asymptomatic patients except in those undergoing surgical implantation of foreign material (e.g., prosthetic joint, heart valve) or invasive urologic procedures. 13. 2007;50(17):e242 and J Am Coll Cardiol. Developed in Collaboration With the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine The mean corpuscular volume was consistent with microcytic anemia. Bleeding history should be obtained from all surgical patients, and appropriate coagulation testing should be considered if the history is abnormal. There are two clinical challenges on both initial management of ACS and handling of DAPT after PCI. First, we aim to identify those patients for whom the perioperative Drug-eluting stents versus bare metal stents prior to noncardiac surgery. Patients with new or unstable cardiopulmonary signs or symptoms should undergo preoperative chest radiography. of patients with PCI for ACS with MI, patients had the greatest risk of adverse events 30 days following surgery and highest overall risk within 3 months of PCI regardless of stent type.5, In a different scenario in which noncardiac surgery is not planned or can be delayed longer, DES may be a more fitting option for PCI. The case against routine preoperative laboratory testing. Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery; European Society of Cardiology (ESC). This article compares and contrasts key guidelines and the evidence they cite, and makes recommendations for the primary care physician evaluating the preoperative patient. Preoperative tests: the use of routine preoperative tests for elective surgery. The patient was still at high risk for complications, but the benefits of noncardiac surgery outweighed the risks. Although contemporary drug-eluting stents (DES) are safer than bare-metal stents (BMS) with respect to late and very late stent thrombosis, it is unclear whether this safety advantage extends to acute and subacute stent thrombosis. PAUL R. DANIELS, MD, is a consultant in the Division of General Internal Medicine at the Mayo Clinic. ; Poldermans D, Henderson WG, The most recent clinical practice guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology for the perioperative cardiovascular assessment and management of patients undergoing noncardiac surgery were both … For example, the National Institute for Clinical Excellence guideline, which may be the most scientifically rigorous of the group, includes 36 tables organized via a flowchart that physicians may reference to make a decision for or against testing.8 Although the guideline is scholarly, its cumbersome nature renders it ineffective in a busy clinical setting. REFERENCES. Accessed December 12, 2012. 5. Fitterman N, Coagulation-related tests (e.g., prothrombin time, activated partial thromboplastin time, platelet count) are often performed preoperatively to identify previously undetected disorders of hemostasis. Immediate, unlimited access to all AFP content. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. This webinar is based on the 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Brown KA, Greaves M; Cardiac Patient For Non Cardiac Surgery -Preoperative Evaluation Dr Pankaj N Surange MBBS,MD,FICMR Graded … ; Vidula MK, Secemsky EA, Yeh RW. Crawford JC, For those non-cardiac surgery patients already receiving a statin, the 2014 guidelines recommend continuation of the statin into the recovery period following surgery. Source: Fleisher LA, Beckman JA, Brown KA, et al. Copyright Â© 2013 by the American Academy of Family Physicians. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. There are several recent reports that current generation DES may be associated with lower rate of stent thrombosis and are as safe as BMS prior to noncardiac surgery if the surgery is more than 6 months after PCI.6 A comparison of DES versus BMS within 1 year prior to noncardiac surgery by Bangalore et al. Sign up for the free AFP email table of contents. 14. Savoldelli GL. To see the full article, log in or purchase access. Macpherson DS. Aortic and major vascular surgery, peripheral vascular surgery, Intraperitoneal or intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery, Ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, cataract surgery. Prediction of Cardiac and Noncardiac Mortality After Percutaneous Coronary Intervention. 2002;96(2):485–496. The RCRI consists of five clinical risk factors and one procedural risk factor. ; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery); American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. For example, the care of patients who require noncardiac surgery and develop ACS preoperatively involves a careful balance between ischemia and bleeding.1. (RCRI = Revised Cardiac Risk Index. Health Technol Assess. Two guidelines recommend using the Revised Cardiac Risk Index (RCRI) to assess the risk of cardiac complications after noncardiac surgery 4,7 (Table 210). Five clinical guidelines make recommendations on the basis of low-level evidence and expert opinion.2,3,5,6,8 The guidelines concur that routine preoperative chest radiography in asymptomatic, otherwise healthy patients is not indicated. J Am Coll Cardiol. Wessler JD, Kirtane AJ. The risk of perioperative complications depends on the condition of the patient before surgery, the prevalence of comorbidities, and the urgency, magnitude, type, and duration of the surgical procedure. KAREN F. MAUCK, MD, MSc, is a consultant in the Division of General Internal Medicine at the Mayo Clinic. Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Outcomes of preoperative bridging therapy for patients undergoing surgery after coronary stent implantation: a weighted meta-analysis of 280 patients from eight studies. Bass EB, / Journals Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery, European Society of Cardiology (ESC), Poldermans D, et al. American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. (80%) being elective non-cardiac surgery.1 Cardiac complications — myocardial infarction (MI), cardiac arrest and other serious arrhythmias, and acute heart failure — occur in about 5% of patients aged 70 years or older undergoing non-cardiac surgery.2,3 Such complications carry 30-day mortality rates between 15% and 20% and If the surgery is non-urgent, then DES is more advantageous than BMS. A recommendation based solely on age is an attractive solution because of its simplicity, but fails to address the question of who is at risk of perioperative cardiac morbidity and mortality. Qaseem A, Multiple professional groups have made recommendations about preoperative CBC, hemoglobin, and hematocrit testing.2,3,8 These recommendations are based on low-level evidence or expert opinion. et al. Because random glucose testing reflects diabetes control over only the past few hours, preoperative random glucose testing in patients with known diabetes rarely alters perioperative management. et al. CopyrightÂ Â© 2020 American Academy of Family Physicians.Â All rights Reserved. et al. Patients who require non-cardiac surgery in acute coronary syndrome. Careful perioperative glucose management affects the surgical outcomes of patients with diabetes. Risk of Adverse Cardiac and Bleeding Events Following Cardiac and Noncardiac Surgery in Patients With Coronary Stent: How Important Is the Interplay Between Stent Type and Time From Stenting to Surgery? 10th ed. Patients in their usual state of health who are undergoing cataract surgery do not require preoperative testing.15,16 A large randomized controlled trial in which more than 19,000 patients undergoing cataract surgeries were randomly assigned to no preoperative testing or to usual care revealed no difference in outcomes between the two groups, and abnormal preoperative test results did not predict outcomes.15 This opinion was reinforced by a 2012 Cochrane review.16.