Beyond Preoperative Clearance: Integrated Cardiovascular Surveillance and Multiorgan Protection in Major Noncardiac Surgery

Vollständiger Abstract

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Perioperative cardiovascular complications remain an important cause of morbidity and mortality after major noncardiac surgery. This integrative review analyzed international evidence on cardiovascular event prediction, physiological and biochemical monitoring, and multiorgan-protection strategies, with particular attention to their applicability in Latin America. Twenty central publications were selected from PubMed/MEDLINE, Scopus, SciELO, LILACS, the Cochrane Library, and international guideline repositories. The evidence included clinical-practice guidelines, randomized trials, prospective cohorts, prediction-model studies, systematic reviews, and consensus statements. The Revised Cardiac Risk Index and NSQIP-MICA provided practical initial estimates but did not capture all relevant dimensions of risk. Their usefulness increased when combined with structured functional-capacity assessment, natriuretic peptides, cardiac troponin, and procedural characteristics. The reported frequency of perioperative myocardial injury ranged from 8.0% in general inpatient surgery to 19.1% in vascular surgery, with most events occurring without ischemic symptoms. Thirty-day mortality increased progressively from 0.1% at peak postoperative high-sensitivity troponin T concentrations below 5 ng/L to 29.6% at concentrations of at least 1,000 ng/L. Hemodynamic evidence emphasized the association of prolonged hypotension with myocardial and renal injury, supporting risk-adapted intraoperative and postoperative surveillance. Pharmacological trials did not identify a universal protective strategy: aspirin increased major bleeding without reducing death or nonfatal myocardial infarction, while clonidine increased clinically important hypotension. Dabigatran reduced major vascular complications from 15% to 11% in selected individuals with myocardial injury after noncardiac surgery. The findings support an integrated pathway in which risk prediction determines monitoring intensity, early detection guides mechanism-directed treatment, and cardiovascular protection is coordinated with renal, cerebral, and pulmonary preservation. This model can be adapted to Latin American healthcare settings through essential and expanded levels of perioperative care.