Include COVID History in Screening Prior to non cardiac Elective Surgeries: JAMA

Many COVID-19 survivors are resuming routine clinical care and being referred for elective surgery. However, it is unclear if a history of recent COVID-19 warrants an additional preoperative cardiac assessment. Therefore, Dr Nidhi Rohatgi and her team explored key considerations for cardiac risk assessment in patients with recent COVID-19 undergoing evaluation for elective noncardiac surgery.

The researchers assessed the data of a large international prospective observational study from the GlobalSurg-COVIDSurg collaborative of 140 231 patients undergoing noncardiac surgery, among which 2.2% had a preoperative COVID-19 diagnosis.

They observed that the postoperative incidence of pulmonary complications was greater in patients undergoing surgery within 7 weeks of a COVID-19 diagnosis (7.8%-8.8%), compared with patients in whom surgery was delayed 7 weeks or more after a COVID-19 diagnosis (2.8%) or those without a COVID-19 diagnosis (2.7%).

Therefore, they recommend, "Delaying elective surgery for a minimum of 7 weeks after COVID-19 diagnosis is advised and longer delays may be reasonable in patients with persistent symptoms".

They also recommend preoperative cardiovascular screening for individuals, incorporating the baseline cardiac risk, history of cardiovascular complications of COVID-19, the severity of COVID-19 illness, and the clinical status after recovery, in consultation with CVD specialists.

With regards to asymptomatic patients, they advised, "Asymptomatic patients at low risk of a perioperative major adverse cardiovascular event (MACE) can proceed to noncardiac surgery without additional testing 7 weeks or more after COVID-19 diagnosis".

However, if MACE risk is elevated, they suggested additional testing to further stratify the perioperative risk. These tests may include a 12-lead electrocardiogram, troponin, brain natriuretic peptide, ambulatory monitoring for arrhythmias, transthoracic echocardiogram, or evaluation for cardiac ischemia as indicated, although data to support preoperative testing in this context are limited.

The authors concluded,

• "Standard clinical practice guidelines for perioperative cardiac risk assessment can be generalized to most patients with COVID-19 undergoing noncardiac surgery.
• The severity of COVID-19 illness should be considered in addition to the traditional cardiac risk. Elective surgery should ideally be deferred 7 weeks or more after COVID-19 diagnosis to reduce postoperative mortality.
• Further delay may be advisable in patients with persistent COVID-19 symptoms, but the optimal timing of surgery is unknown.
• Additional preoperative cardiovascular testing may be considered in selected patients, but such evaluation must be individualized in consultation with CVD specialists.
• Ultimately, prospective trials evaluating the optimal approach to preoperative cardiovascular risk stratification after COVID-19 are necessary."

For further information:

DOI: 10.1001/jamasurg.2021.6953