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Preoperative Cardiac Risk Assessment

Author/s: 
Raslau, D, Bierle, DM, Stephenson, CR, Mikhail, MA, Kebede, EB, Mauck, KF

Major adverse cardiac events are common causes of perioperative mortality and major morbidity. Preventing these complications requires thorough preoperative risk assessment and postoperative monitoring of at-risk patients. Major guidelines recommend assessment based on a validated risk calculator that incorporates patient- and procedure-specific factors. American and European guidelines define when stress testing is needed on the basis of functional capacity assessment. Favoring cost-effectiveness, Canadian guidelines instead recommend obtaining brain natriuretic peptide or N-terminal prohormone of brain natriuretic peptide levels to guide postoperative screening for myocardial injury or infarction. When conditions such as acute coronary syndrome, severe pulmonary hypertension, and decompensated heart failure are identified, nonemergent surgery should be postponed until the condition is appropriately managed. There is an evolving role of biomarkers and myocardial injury after noncardiac surgery to enhance risk stratification, but the effect of interventions guided by these strategies is unclear.

Keywords 
cardiac preoperative assessment risk factors heart failure

Management of Patients With Acute Ischemic Stroke

Author/s: 
Cifu, A.S., Brorson, J.R.

Guideline title 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Release date January 24, 2018

Prior version 2013

Developer American Heart Association (AHA)/American Stroke Association (ASA)

Funding source AHA/ASA

Target population Adult patients with acute arterial ischemic stroke

Major recommendations

  • Regional systems of stroke care should be developed that include health care facilities providing initial emergency care and those capable of endovascular stroke treatment, to which rapid transport can be arranged when appropriate (high-quality evidence; strong recommendation).

  • Intravenous alteplase is recommended for patients meeting detailed eligibility requirements within 3 hours of ischemic stroke onset (high-quality evidence; strong recommendation) and between 3 and 4.5 hours of ischemic stroke onset (moderate-quality evidence; strong recommendation).

  • Mechanical thrombectomy with a stent retriever is recommended for patients with a causative occlusion of the internal carotid artery or proximal middle cerebral artery with at least moderately severe presenting stroke deficits (National Institutes of Health Stroke Scale [NIHSS] score ≥6) and absence of evidence of widespread established infarction on brain imaging, when endovascular treatment can be initiated within 6 hours of symptom onset (high-quality evidence; strong recommendation).

  • Mechanical thrombectomy with a stent retriever is also recommended for certain acute ischemic stroke (AIS) patients presenting at later times (moderate- to high-quality evidence; strong recommendation).

Keywords 
stroke ischemia stents
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