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

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

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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.

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.