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COVID-19: Beyond Tomorrow
January 12, 2022

Perioperative Cardiovascular Considerations Prior to Elective Noncardiac Surgery in Patients With a History of COVID-19

Author Affiliations
  • 1Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 2Division of Cardiology, Department of Medicine, New York University School of Medicine, New York
  • 3Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
JAMA Surg. 2022;157(3):187-188. doi:10.1001/jamasurg.2021.6953

Patients with cardiovascular risk factors (eg, age, hypertension, diabetes, obesity) and established cardiovascular disease (CVD) have excess morbidity and mortality with COVID-19.1 Acute cardiovascular complications of COVID-19 can include myocardial injury, acute coronary syndrome, heart failure, arrhythmias, dysautonomia, and thromboembolism.1 It remains unknown whether these cardiovascular complications of COVID-19 persist beyond the acute phase of illness. Prior studies indicate that hospitalization with non–COVID-19 pneumonia may be associated with an increased risk of CVD up to 10 years after the initial infection.2

Many COVID-19 survivors are resuming routine clinical care and being referred for elective surgery. It is unclear if a history of recent COVID-19 warrants additional preoperative cardiac assessment. We outline key considerations for cardiac risk assessment in patients with recent COVID-19 undergoing evaluation for elective noncardiac surgery.

In a large international prospective observational study from the GlobalSurg-COVIDSurg collaborative of 140 231 patients undergoing noncardiac surgery, 2.2% had a preoperative COVID-19 diagnosis.3 A majority of the patients with a preoperative COVID-19 diagnosis were younger than 70 years, were American Society of Anesthesiologists physical status class of 1 or 2, had revised cardiac risk index of 0 or 1, and reported either asymptomatic COVID-19 or experienced symptom resolution prior to the surgery. Among surgeries performed within 2 weeks of a COVID-19 diagnosis, 70.3% were emergent. The 30-day adjusted postoperative mortality was 3.6% to 4.1% in patients undergoing surgery within 7 weeks of a COVID-19 diagnosis, but only 1.5% in patients undergoing surgery 7 weeks or more after a COVID-19 diagnosis, similar to patients without a COVID-19 diagnosis. This association between postoperative mortality and the timing of COVID-19 diagnosis was observed irrespective of age, American Society of Anesthesiologists physical status class, major or minor surgery, emergent or elective surgery, or COVID-19 symptom status (asymptomatic, ongoing, or resolved respiratory or nonrespiratory symptoms). Among patients undergoing surgery 7 weeks or more after a COVID-19 diagnosis, those with ongoing COVID-19 symptoms had substantially higher 30-day postoperative mortality (6.0%) when compared with asymptomatic patients (1.3%) or those with symptom resolution (2.4%). Unfortunately, perioperative cardiovascular complications and causes of death were not reported in these analyses. However, the postoperative incidence of pulmonary complications was also 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%). Although we cannot exclude confounding by surgical indication in these observational analyses, based on these data, 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.

Independently, the American Society of Anesthesiologists and Anesthesia Patient Safety Foundation expert consensus statement proposed delaying elective surgery for 4 weeks or more after asymptomatic or mild (nonrespiratory) COVID-19, 6 weeks or more for patients with moderate illness not requiring hospitalization, 8 to 10 weeks or more for patients with severe COVID-19 requiring hospitalization, immunocompromised patients, and those with diabetes, and 12 weeks or more among critically ill patients with COVID-19.4

The foundation of perioperative cardiac risk assessment includes a careful history and physical examination, optimization of cardiovascular risk factors, ascertainment of functional capacity, and integrated risk assessment using risk prediction tools and/or biomarkers to guide additional cardiac evaluation.5 Surgery-specific risks should be considered based on the need for general anesthesia, duration of surgery, expected blood loss, anticipated hemodynamic changes, and surgical expertise.

The optimal approach to preoperative cardiovascular screening after COVID-19 is not yet well defined. Expert consensus statements have proposed systematic cardiovascular screening for collegiate and professional athletes with COVID-19, recommending a 12-lead electrocardiogram, transthoracic echocardiogram, and measurement of high-sensitivity troponin prior to return to play.6 If the initial testing is abnormal, or if myocarditis is suspected, then return to athletics is deferred for 3 to 6 months. These recommendations apply to a young, otherwise healthy population with few comorbidities and excellent baseline functional capacity and may not be generalizable to older or comorbid adults undergoing noncardiac surgery.

Preoperative cardiovascular screening must be individualized, incorporating the baseline cardiac risk, history of cardiovascular complications of COVID-19, severity of COVID-19 illness, and the clinical status after recovery, in consultation with CVD specialists. Optimization of COVID-19–associated cardiovascular disease should be undertaken when feasible to attenuate the perioperative cardiovascular risk. There may also be an interaction between the cardiac risk and ongoing respiratory symptoms, hypoxia, abnormal pulmonary function, or occult thromboembolism in patients with COVID-19. The most common postacute sequelae of COVID-19 are persistent dyspnea (88%), fatigue (45%), chest pain (43%), and palpitations (11%).7 Patients with even mild COVID-19 may have lingering physical deconditioning and poor functional capacity for 3 months or more after the acute illness. These COVID-19–associated symptoms may complicate preoperative cardiovascular risk assessment.

Asymptomatic patients at low risk of a perioperative major adverse cardiovascular event can proceed to noncardiac surgery without additional testing 7 weeks or more after COVID-19 diagnosis (Table). Selected patients who are at an elevated risk of perioperative major adverse cardiovascular event, especially those with a history of cardiovascular complications of COVID-19, may warrant additional testing to further stratify the perioperative risk but this must be individualized in consultation with CVD specialists. These tests may include 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.

Table.  Proposed Timing of Elective Noncardiac Surgery in Patients With a History of COVID-19
Proposed Timing of Elective Noncardiac Surgery in Patients With a History of COVID-19

In conclusion, standard clinical practice guidelines for perioperative cardiac risk assessment can be generalized to most patients with COVID-19 undergoing noncardiac surgery.5 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.

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Article Information

Corresponding Author: Nidhi Rohatgi, MD, MS, 300 Pasteur Dr, HCO32D, MC 5210, Stanford, CA 94305 (nrohatgi@stanford.edu).

Published Online: January 12, 2022. doi:10.1001/jamasurg.2021.6953

Conflict of Interest Disclosures: Dr Smilowitz reports personal fees from Abbott Vascular Consulting. No other disclosures were reported.

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COVIDSurg Collaborative; GlobalSurg Collaborative.  Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study.   Anaesthesia. 2021;76(6):748-758. doi:10.1111/anae.15458PubMedGoogle ScholarCrossref
Anesthesia Patient Safety Foundation. American Society of Anesthesiologists and Anesthesia Patient Safety Foundation Joint Statement on Elective Surgery and Anesthesia for Patients After COVID-19 Infection. Accessed February 20, 2021. https://www.apsf.org/news-updates/asa-and-apsf-joint-statement-on-elective-surgery-and-anesthesia-for-patients-after-covid-19-infection/.
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Phelan  D, Kim  JH, Elliott  MD,  et al.  Screening of potential cardiac involvement in competitive athletes recovering from COVID-19: an expert consensus statement.   JACC Cardiovasc Imaging. 2020;13(12):2635-2652. doi:10.1016/j.jcmg.2020.10.005 PubMedGoogle ScholarCrossref
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2 Comments for this article
In Reply to--Perioperative Cardiovascular Considerations Prior to Elective Noncardiac Surgery in Patients With a History of COVID-19
Avital O'Glasser, MD | Oregon Health & Science University
We read with great interest this viewpoint regarding preoperative cardiovascular considerations & assessment prior to elective surgery for survivors of COVID-19 (1). Given this actively evolving clinical landscape, we applaud the authors for their keen summary & analysis of the available data. With global COVID-19 cases now in the nine digits and millions of adult surgeries performed worldwide annually, the number of COVID-19 survivors presenting for elective, & non-elective, surgery will remain elevated for the foreseeable future.

As the authors note, careful history & examination are the hallmark of perioperative evaluation. Preoperative cardiac assessment is more than “stress
test/no stress test”, with additional considerations necessary for the assessment of heart failure, arrhythmias, & valvular disease (2). In addition to the risk of COVID-19-induced myocarditis, our group remains very concerned about the risk of COVID-19-induced cardiomyopathy. We greatly appreciate the authors recommending that current clinical practice guidelines be followed for post-COVID patients with elevated risk of MACE. We add our own emphasis on assessing for COVID-19-induced cardiomyopathy or arrhythmias via preoperative testing, particularly in the presence of decreased functional capacity (3).

In addition to history, exam, & first-pass cardiac tests such as EKG, we remain curious as to the potential role of preop cardiac biomarkers in the risk stratification of COVID-19 survivors. Our institution implemented a rigorous post-COVID-19 preoperative assessment in summer 2020, which includes biomarkers (3). Our group has already identified cases of COVID-19-induced cardiomyopathy via this protocol (unpublished data). Given the differences in recommendations for preop cardiac biomarkers between the American &Canadian guidelines, we eagerly await possible convergence of the guidelines, at least on the assessment of COVID survivors, in their next iterations (2,4).

Finally, attention is also needed to the intersection between Long COVID & periop medicine. Long COVID can manifest with POTS, orthostatic hypotension, palpitations, & other cardiac symptoms. Long COVID can occur even after “mild” COVID-19 illness, & the preop clinician must be attune to this clinical entity. Moreover, we have very little data on cardiovascular manifestations & Long COVID after infection with Omicron.

We wholeheartedly second the authors’ concluding statement about eagerly awaiting more data about this clinical conundrum that impacts large volumes of perioperative patients.

Avital Y. O'Glasser, MD, FACP, FHM
Katie J. Schenning, MD, MPH, MCR

1.Rohatgi N, Smilowitz NR, Reejhsinghani R. Perioperative Cardiovascular Considerations Prior to Elective Noncardiac Surgery in Patients With a History of COVID-19. JAMA Surg. Published online January 12, 2022.
2.Fleisher LA, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215-2245.
3.Bui N, Coetzer M, Schenning KJ, O'Glasser AY. Preparing previously COVID-19-positive patients for elective surgery: a framework for preoperative evaluation. Perioper Med (Lond). 2021 Jan 7;10(1):1.
4.Duceppe E, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017 Dec;33(12 ):1735.
Not only Covid-19, but also “Long Covid” Disease Impacts Cardiovascular Postoperative Risk: Pathophysiological Remarks
ANTONIO MANENTI, MD. | University of Modena and Reggio Emilia
The interesting paper by Rohatgi et al.1 focuses the changed perioperative cardiovascular risk in patients after Covid-19 disease. We would recall attention to some pathophysiological elements persisting beyond the 12th week from recovery, referring to a “long Covid” (LC) syndrome and negatively impacting on postoperative also of noncardiac surgical procedures. The SARS-Cov2 disease has to be considered a potential multiorgan disease for the widespread presence of ACE2 receptors in vascular endothelia, where virions produce an inflammatory “endotheliitis”.2 This can be followed by an hypersensitive immune leukocytoklastic like vasculitis, where the platelets overproduction contributes to develop microthromboses.2-4 In some weeks, this chain of pathological events causes a progressive endothelial dysfunction, expressing also with an accelerated worsening of atherosclerotic plaques and increased risk of embolization.1 Moreover, in the thoracic aorta, ”vasa vasorum” thrombosis favors the onset of acute aortopathies, such as aortitis, penetrating endothelial ulcer, intramural hematoma or dissection, often interconnected; equally, a pre-existing aortic aneurysms can increase in size, also for the action of activated metalloproteinases.5 The virions toxicity can affect the myocardial tissue, generating a proper myocarditis through a direct cellular damage, followed by infiltration of circulating mononuclear elements, sometimes involving also the cardiac conducting system.2,3 Respectively, this can impair the cardiac function and generate arrhythmogenic channelopathies. The coronary system too can undergo the same endothelial dysfunction and atherosclerosis progression, up to a myocardial ischemia. In mid-term, another cardiac damage, specifically involving the right chambers, can follow increased pulmonary vascular resistances, consequent, during the Covid-19 acute phase, to hypercapnia, alveolar microvessels vasospasm, “endotheliitis”, and increased Endothelin-1 release.2 In LC this can translate in thrombosed alveolar capillaries, thickened interalveolar septa and areas of secondary pulmonary fibrosis.
Practically, in the current pandemic period, the presence of a subclinical LC can be suspected, after a Covid-19 severe form, also in absence of its specific signs, such as mild discomfort, weakness, headache and joint pain, common with other viral diseases. We underline its negative impact on the cardiovascular system, with the risk of unexpected complications also after noncardiac procedures, that act as trigger factors. In perspective, all this implies a careful preoperative study before any surgical decision.

Luca Roncati, MD
Antonio Manenti, MD
Gianrocco Manco, MD

Authors affiliations: Department of Pathology (Roncati), Surgery (Manenti, Manco), University of Modena and Reggio Emilia; Modena, Italy.
Corresponding Author: Antonio Manenti, Polyclinic Hospital, v. Pozzo; 41121 Modena, Italy (antonio.manenti@unimore.it).

1. Rohatgi N, Smilowitz NR, Reejhsinghani R. Perioperative cardiovascular considerations prior to elective noncardiac surgery in patients with a history of COVID-19. JAMA Surg. 2022 Jan 12. doi: 10.1001/jamasurg. 2021.6953.
2. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet. 2020; 395 (10234):1417-18. doi: 10.1016/S0140-6736(20)30937-5.
3. Roncati L, Ligabue G, Fabbiani L, Malagoli C, Gallo G, Lusenti B, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol. 2020; 217:108487. doi