During emergency surgeries, cardiac complications are significantly increased, up to 2–5 times more frequent when compared to similar elective procedures. Due to the nature of emergency surgery, it is not possible to optimize the patient with significant cardiac comorbidities that are currently not under control. In addition, the nature of the surgery and the insult to the system that has already occurred may make perioperative precautions (i.e., maintenance of blood pressure, avoidance of anemia, use of invasive monitors, etc.) all that one can do to decrease perioperative morbidity and mortality.

If the surgery is emergent, then surgery needs to happen regardless of the patient’s comorbidities. The physician should determine cardiac status and tailor anesthetic management based on that. However, if the surgery is not an emergency, the physician needs to determine the surgical risk, whether or not the patient has active cardiac conditions, clinical risk factors, and what the patient’s functional capacity is, and tailor preoperative workup based on this.

If a patient has any active cardiac conditions, this mandates further evaluation and intensive management, which may result in surgical delay. Active cardiac conditions are listed in Table 2.3. If a patient has active cardiac conditions involving the coronary arteries, then one must take into consideration how long the surgery can wait. This timing is related to the period that the patient needs to be on antiplatelet medication after revascularization:

Surgical risk is divided into three categories—high (vascular), intermediate, and low (Table 2.4). The evaluating clinician must also take into account the type of surgery the patient is scheduled to undergo. Factors related to the type of surgery are a function of the degree of invasiveness. Therefore, the amount of expected blood loss, duration of the procedure, potential patient-related stress, and fluid shifts associated with the procedure all need to be taken into account. Once all of these factors are evaluated, a final decision can be made as to the patient’s potential for experiencing a perioperative cardiac complication. Patients undergoing low-risk surgery do not need any additional cardiac testing, unless of course active cardiac conditions are present.

Functional capacity involves assessing metabolic equivalent of task (MET) (Table 2.5). If the patient is unable to obtain an exercise level of 4 MET or MET cannot be obtained, further testing may be warranted depending on the patient’s clinical risk factors and the invasiveness of surgery. Patients who can achieve more than 4 MET rarely need any additional cardiac testing.

If the patient is undergoing intermediate-risk surgery and has an activity level of less than 4 MET, one must establish how many clinical risk factors the patient has (Table 2.6). If there are no clinical risk factors then one may proceed with surgery. If one or more risk factors are present, then additional cardiac testing may be considered if it will change management. If no cardiac testing is decided, then one may proceed with surgery with heart rate control.

If the patient is undergoing high-risk surgery and has an activity level of less than 4 MET, one must establish how many clinical risk factors the patient has. If there are no clinical risk factors, then it may be fine to proceed with surgery. If there are 1–2 clinical risk factors, then consider additional cardiac testing if it will change management, or proceed to the operating room with heart rate control. If there are three or more clinical risk factors, then proceed with additional cardiac testing.

Both asthma and COPD increase the risk of postoperative respiratory failure. The history should include questions about the type of therapy including steroid use, severity (ER visits, intubation), and any aggravating factors, such as aspirin use or exercise. The patient should be instructed to continue their inhalers as usual and to bring them with them on the day of surgery. If the patient has worsening symptoms or poorly controlled COPD/asthma, a pulmonary consult may be warranted.

The evaluating physician should inquire about snoring (confirmed by a partner), hypertension, chronic fatigue, and obesity. Patients that wear continuous positive airway pressure (CPAP) masks should be instructed to bring their machines on the day of surgery.

Patients should be instructed to stop smoking before surgery. Smoking increases airway reactiveness, inhibits ciliary motility to remove secretions, causes poor wound healing, and increases the rate of complications after surgery. The maximal beneficial effects occur if smoking is stopped for at least 8 weeks prior to surgery. However, carboxyhemoglobin (carbon monoxide—CO) levels decrease in the first 12–24 h after stopping smoking (improves oxygenation). Both nicotine and CO have negative effects on the heart (increase oxygen demand, decrease contractility). It should be noted that in some patients, airway reactiveness and secretions might increase paradoxically for about a week after smoking cessation.