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 Table of Contents  
REVIEW ARTICLE
Year : 2023  |  Volume : 2  |  Issue : 1  |  Page : 17-25

Cardiac evaluation of patients with diabetes mellitus before noncardiac surgery


1 Department of Endocrinology and Metabolism, Health World Hospitals, Durgapur, West Bengal, India
2 Department of Endocrinology, K. S. Hegde Medical Academy, Mangalore, Karnataka, India

Date of Submission26-Jun-2022
Date of Decision10-Aug-2022
Date of Acceptance02-Sep-2022
Date of Web Publication18-Jan-2023

Correspondence Address:
Lakshmi Nagendra
Department of Endocrinology, K. S, Hegde Medical Academy, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdrp.cdrp_CDRP_16_22

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  Abstract 


Up to 40% of patients undergoing elective surgeries have underlying diabetes mellitus (DM), and therefore an elevated risk of perioperative adverse cardiovascular outcomes. Preoperative cardiovascular risk assessment and therapeutic optimization are warranted in all patients with DM. This is an updated review on preoperative evaluation of cardiac risk in patients with DM undergoing surgery and strategies to minimize the risk. This article summarizes the current evidence and recommendations for cardiac evaluation in DM before noncardiac surgery. Preoperative risk estimation includes risk stratification of the proposed surgery and estimating the risk in the patient using available risk calculators such as the Revised Cardiac Risk Index and assessment of the functional status of the patient in terms of metabolic equivalents of tasks. Preoperative cardiac investigations such as electrocardiogram, echocardiography, stress testing, or cardiac biomarkers should be done in high-risk surgeries, and in certain subsets of patients undergoing low- or intermediate-risk surgeries. Additional testing and preoperative optimization are warranted in patients with heart failure and reduced or preserved ejection fraction, those with cardiac autonomic neuropathy, hypertension with or without end-organ damage, and patients undergoing transplant surgery, all of which are discussed in the current review.

Keywords: Cardiac autonomic neuropathy, preoperative risk, revised cardiac risk index


How to cite this article:
Mondal S, Nagendra L. Cardiac evaluation of patients with diabetes mellitus before noncardiac surgery. Chron Diabetes Res Pract 2023;2:17-25

How to cite this URL:
Mondal S, Nagendra L. Cardiac evaluation of patients with diabetes mellitus before noncardiac surgery. Chron Diabetes Res Pract [serial online] 2023 [cited 2023 Feb 5];2:17-25. Available from: https://cdrpj.org//text.asp?2023/2/1/17/368024




  Introduction Top


The prevalence of diabetes is on the rise. With diabetes currently affecting around 537 million adults worldwide, it is becoming more commonplace to have patients with diabetes presenting for surgery.[1] The reported prevalence of hyperglycemia and diabetes in surgical patients ranges from 10% to 40%.[2] It is well-established that they have higher rates of complications, longer stays in hospital, and higher mortality compared to patients without diabetes.[3],[4]

Higher complications and mortality in patients with diabetes following surgery is brought about by a complex interplay of various factors. The trauma and increased sympathetic activity associated with surgery lead to increased production of stress hormones with simultaneous decrease in insulin sensitivity and insulin production. The resulting hyperglycemia due to abnormal glucose hemostasis is a risk factor for impaired wound healing, postoperative sepsis, endothelial dysfunction, and cerebral ischemia.[5] Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes presenting for surgery. Up to 50% of type 2 diabetes mellitus (DM) patients have unrecognized myocardial infarction events. Chronic complications of diabetes, especially cardiac autonomic neuropathy (CAN) can lead to increased cardiovascular events and mortality.[6]

A comprehensive strategy to optimize patients with diabetes undergoing surgery is vital to minimize perioperative complications and improve outcomes. Preoperative evaluation for surgical procedures in patients with diabetes should include an assessment of glycemic control and any diabetes-associated complications. Our review focuses on the evidence for risk assessment and optimal testing to reduce perioperative cardiovascular events prior to a noncardiac surgery in patients with diabetes. We also propose a practical, stepwise approach for evaluation of the patient with diabetes presenting for surgery.


  Methods Top


We conducted a literature search on PubMed and Google Scholar to identify relevant articles published until May 2022 on cardiac evaluation in diabetes before general anesthesia. The terms “cardiac evaluation in diabetes before surgery,” “preoperative cardiac risk stratification in diabetes,” and “cardiac assessment in diabetes before surgery” were used. Clinical practice guidelines and randomized control trials were prioritized for review.


  Discussion Top


Estimating perioperative risk

Step 1: Assess the urgency of the proposed surgery

Estimating perioperative risk begins with assessment of the urgency of the proposed surgery. An emergency operation is one, in which life or limb is at risk if not immediately in the operating room, and there is little or no time for clinical evaluation, usually within 6 hours. An urgent procedure is one in which a limited clinical examination may be possible, usually when life or limb is at risk if the patient is not in the operating room within 6–24 hours. A time-sensitive procedure is one in which a delay of more than 1-6 weeks for an evaluation will have a detrimental impact on the outcome. An elective procedure is one in which the procedure could be delayed for up to 1 year without any impact on the outcome.[7] Patients requiring urgent or emergency surgeries are at an increased risk of a perioperative cardiovascular event, regardless of baseline risk. In these cases, perioperative surveillance for cardiac events and continuation of chronic cardiovascular medical therapy form the cornerstones of management.[8]

Step 2: Assess cardiac risk of the proposed surgery

With regard to cardiac risk, surgical interventions can be divided into low-risk, intermediate-risk, and high-risk groups, with estimated 30-day cardiac event rates (cardiac death and myocardial infarction) of 1%, 1%–5%, and > 5%, respectively)[8],[9] [Table 1].
Table 1: Risk stratification of noncardiac surgeries

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Step 3: Assess functional capacity of the patient

Determination of functional capacity is a key step in preoperative cardiac risk assessment. Functional capacity is subjectively assessed in units of the metabolic equivalent of tasks (METs).[10] Functional capacity can be estimated from the ability to perform the activities of daily living. One MET represents metabolic demand at rest; climbing two flights of stairs represents four METs, and strenuous sports such as swimming is equivalent to 10 METs. The inability to climb two flights of stairs or run a short distance (four METs) indicates poor functional capacity and is associated with an increased incidence of postoperative cardiac events.[7],[8]

Step 4: Patient risk stratification (revised cardiac risk index)

There are multiple risk calculators available to calculate the perioperative risk of Major Adverse Cardiovascular Events (MACE). Diabetes is a component of almost all risk indices. The six-component Revised Cardiac Risk Index (RCRI) is a relatively simple to use calculator. One point is assigned for each of the following: insulin-dependent diabetes, cerebrovascular disease, ischemic heart disease, heart failure (HF), chronic kidney disease (serum creatinine level >2 mg/dl), and high-risk surgery (intraperitoneal, intrathoracic, or vascular). The presence of insulin-requiring DM with one another risk factor from the RCRI denotes high risk of MACE.[11]

Preoperative cardiac investigations in patients with diabetes mellitus

Electrocardiogram

An electrocardiogram (ECG) is recommended only in high-risk and intermediate-risk surgeries in patients with risk factors. The indications for an ECG are summarized in [Table 2].[8]
Table 2: Indications for preoperative electrocardiography in patients with diabetes mellitus undergoing noncardiac surgery

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Echocardiography

Rest Echocardiography may be considered in patients undergoing high risk surgery. Combining the recommendations laid down by the American Heart Association and the American College of Cardiology (AHA/ACC) guidelines and the European Society of Cardiology and the European Society of Anaesthesiology (ESC/ESA) guidelines, preoperative echocardiography is indicated for those with:

  1. Dyspnea of unknown etiology
  2. Those with a known history of HF with worsening dyspnea, edema, or recent syncope
  3. Reassessment of left ventricular (LV) function in clinically stable patients with previously documented LV dysfunction more than a year ago
  4. Established case or hypertrophic or restrictive cardiomyopathy.


Stress testing

Stress testing is recommended in patients with more than two risk factors and poor functional capacity, posted for high-risk surgery The indications for stress testing are summarized in [Table 3].[8]
Table 3: Indications for preoperative stress testing in patients with diabetes mellitus undergoing noncardiac surgery

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Cardiac biomarkers

Commonly used cardiac biomarkers include the B-type natriuretic peptide (BNP), a polypeptide released by cardiomyocytes in response to atrial stretch, and the N-terminal pro-BNP (NT-proBNP). In a meta-analysis including 18 prospective observational studies, a value of BNP levels >92 pg/mL or NT-pro BNP levels >300 pg/mL is associated with an increased risk of death or postoperative myocardial infarction at 30 days.[12] One study showed that for patients undergoing vascular surgery or urgent surgery, the inclusion of preoperative natriuretic peptide to a risk model containing age, RCRI (≥3) improved sensitivity to predict 30-day perioperative cardiovascular events, and reclassified up to 18% of the cases.[12],[13]

Routine preoperative assessment of cardiac biomarkers is not recommended by the AHA/ACC guidelines while the ESC/ESA recommend measuring them in selected high-risk individuals (METs ≤4 or with a RCRI value >2 for nonvascular surgery and >1 for vascular surgery).[7],[8] Canadian guidelines recommend measurement of NT-pro BNP or BNP levels before noncardiac surgery in all patients aged >65 years and in patients between 45 and 64 years of age with a history of established cardiovascular disease or a RCRI ≥1.[14] Postoperative surveillance of cardiac troponin levels during the first 48 h after higher-risk surgery has been suggested for patients with higher scores on preoperative risk calculators (e.g., RCRI >1) if clinical decision-making would be altered by the results of the test.[11]

Coronary angiography and revascularization

If preoperative cardiac risk assessment with the abovementioned tests including stress testing is suggestive of coronary artery disease (CAD), the benefit of coronary angiography and revascularization preoperatively is unclear due to the lack of evidence from large randomized control trials. In the coronary artery revascularization prophylaxis trial, 510 patients with CAD who were scheduled for vascular surgery were randomly allocated to either coronary artery revascularization or no coronary artery revascularization before surgery. Postoperative myocardial infarction within 30 days (12% in the revascularization group vs. 14% in the no revascularization group; P = 0.37) and long-term mortality at a median follow-up of 2.7 years (22% vs. 23%, respectively; P = 0.92) were not different between the groups. However, the limitation of the trial was that patients with left main CAD and reduced left ventricular ejection fraction were excluded from the study.[15] The AHA/ACC guidelines and the ESC/ESA have slightly different recommendations on prophylactic revascularization before surgery. The AHA/ACC guidelines do not recommend routine cardiac revascularization before noncardiac surgery.[7] In contrast, the ESC/ESA guidelines suggest that prophylactic cardiac revascularization may be considered before high-risk surgery if there is evidence of substantial stress-induced ischemia.[8]

For those who have undergone coronary revascularization, it is reasonable to delay nonurgent surgery by at least 4 weeks (and ideally 3 months) after angioplasty with bare metal stent, at least 6 months (and ideally 12 months) after angioplasty with drug-eluting stents, and at least 2 weeks after a balloon angioplasty procedure.[7] For those in whom the risk of delaying surgery would exceed the risk of a stent thrombosis, a cautious decision to proceed with surgery may be taken. In that case, aspirin must be continued while the other antiplatelets should be withheld for a short duration before surgery (5 days for clopidogrel and ticagrelor and 7 days for prasugrel) and restarted immediately after.

Special situations

Heart failure

People with DM are predisposed to a 2-to-3-fold increased risk for HF. Around 36%–47% of patients with HF with reduced ejection fraction (HFrEF) and 32%–33% of those with HF with preserved EF (HFpEF) have DM.[16] While many cases are secondary to underlying CAD, hypertension, or valvular heart disease, the presence of diabetes per se can predispose to the entity of “diabetic cardiomyopathy.”

Heart failure with reduced ejection fraction

In the original version of the Cardiac Risk Index (CRI) for preoperative risk stratification of patients, two out of the nine independent predictors of serious cardiac complications were related to HFrEF, namely, the presence of preoperative third heart sound and elevated jugular venous pressure. In fact, these factors had the strongest association with perioperative MACE.[17] Almost all subsequent risk scores also incorporated history of HF as a risk factor.[18]

The 30-day postoperative mortality rate is significantly higher in patients with nonischemic HF (9.3%) followed by ischemic HF (9.2%), atrial fibrillation (AF) (6.4%), or CAD (2.9%) in a population-based study involving 38,047 patients.[19] This is a particularly important finding because most perioperative risk prediction models place greater emphasis on CAD than on HF. In addition, the stability of a patient with HF also plays a significant role. Patients with stable HF were found to have perioperative mortality rates to those without HF but had longer hospital stays, higher rates of hospital readmission, and higher long-term mortality rates.[20]

Heart failure with preserved ejection fraction

As many as 60%–75% of asymptomatic, well-controlled, patients with T2DM can have diastolic dysfunction of varying severity, and women have up to threefold increased risk compared to men.[21],[22] In a large meta-analysis using individual patient data, those with HFpEF had lower all-cause mortality rate than those with HFrEF but mortality rate was still higher than those without HF.[23]

Perioperative considerations in patients with diabetes mellitus and heart failure

For a patient presenting with acute HF, it is prudent to delay nonurgent surgeries at least 3 months after the event, during which every attempt must be made for optimization of medical therapy of HF. For patients with HFrEF, this would include initiation and dose titration, as required, of Renin-Angiotensin-Aldosterone System (RAAS) blockers (angiotensin receptor-neprilysin inhibitor [ARNIs] in New York Heart Association (NYHA) class II and III and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers [ACEi/ARBs] for class II and IV), beta-blockers, Mineralocorticoid Receptor Antagonist (MRA), diuretics as required, and sodium-glucose linked-cotransporter-2 inhibitors (SGLT2i). There is accumulating evidence for the benefit of SGLT-2i use in both acute de novo and decompensated chronic HF.[24],[25]

For those with an established diagnosis of chronic HF, preoperative echocardiography, and cardiac biomarkers are indicated as outlined in sections “echocardiography” and “cardiac biomarkers”. Preoperative goal-directed medical therapeutic optimization should be ensured. Among the medications used in the setting of HF, for a patient with chronic HF on beta-blockers, they must be continued till surgery at the same dosage. If there is inadequate time for optimum dose titration, they should not be initiated preoperatively. ACEi/ARBs should be omitted on morning of surgery, with close monitoring of BP and hemodynamic status perioperatively. A patient who requires initiation of ACEi/ARB for HF in the preoperative period should ideally be started on these agents at least 1 week before surgery. Those with HFpEF need very close attention to maintaining volume status and control of afterload with adequate diuresis. It may be reiterated here, that, for the management of HFpEF, there is more evidence of benefit with SGLT2i than Renin-Angiotensin-Aldosterone System (RAAS) blockers (ARNi, ARB/MRA), and therefore the use of SGLT2i is based on Grade 2a recommendation, whereas that for the RAAS blockers is Grade 2b.[26] The SGLT2i should be discontinued at least 3 days before surgery.

Cardiac autonomic neuropathy (CAN)

Cardiac autonomic neuropathy in diabetes mellitus and perioperative risks

Several studies have reported an increased mortality rates in patients with clinically overt as well as asymptomatic CAN, and a meta-analysis has reported the pooled estimate of the relative risk to be 2.14 (1.83–2.51).[27],[28],[29],[30] Burgos et al. found that perioperatively, vasopressor support was needed more often in individuals with diabetes with autonomic dysfunction than in those without.[31] Patients with CAN have greater hemodynamic instability during anesthesia and surgery. There is an increased requirement for vasopressor support due to inadequate ability of vasoconstriction and tachycardia to compensate for the vasodilating effects of anesthetic agents. Therefore, they exhibit profound decreases in heart rate and arterial blood pressure during induction of anesthesia and less tachycardia and hypertension after tracheal intubation and extubation.[31] Another study demonstrated that there is more severe intraoperative hypothermia.[32] This would in turn lead to decreased drug metabolism and impaired wound healing. Sobotka et al. showed that some patients with diabetes with autonomic neuropathy can have a reduction in hypoxic-induced ventilatory drive.[33] Therefore, preoperative cardiovascular autonomic screening to identify those with CAN will help prioritize patients at high risk for intraoperative complications and provide useful information for planning the anesthetic management in them.

Cardiac autonomic neuropathy: Diagnostic tests

Cardiovascular reflex tests still form the gold standard for the diagnosis of CAN [Table 4]. Ideally, all patients with type 2 DM or with type 1 DM for 5 years should be screened for CAN, particularly those at greater risk of CAN due to uncontrolled glycemic status, cardiovascular risk factors, neuropathy, Charcot foot, nephropathy, and retinopathy.[30]
Table 4: Diagnostic tests for cardiac autonomic neuropathy

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Following the discussion in two important meetings (San Antonio conference on diabetic neuropathy held in 1988 and the second conference in 1992) jointly sponsored by the American Diabetes Association and American Academy of Neurology, three tests of heart rate (HR) response to (1) deep breathing, (2) standing, and (3) the Valsalva maneuver and two tests of blood pressure (BP) response to standing/passive tilting and sustained handgrip are recommended for routine screening of CAN.[39],[40] One abnormal HR test or two borderline results are considered “early” CAN, two or more abnormal results indicate “definite involvement,” whereas “severe involvement” is indicated when orthostatic hypotension is present.[41] Results for the patient are analyzed by positioning the values on available normative graphs as a function of age and should be considered abnormal if it falls below the 5th percentile for age.[34],[42] Ambulatory BP monitoring may be useful in patients with suspected CAN to detect attenuation (nondipping) or loss of nocturnal fall of BP (reverse dipping) and to ensure round-the-clock BP control with antihypertensives. In patients undergoing preoperative evaluation, a prolonged corrected QT interval (QTc) on ECG could indicate the presence of underlying CAN and is an independent predictor of mortality.[41],[43]

Hypertension in patients with diabetes mellitus: recommendations for preoperative evaluation and management

Patients with newly diagnosed hypertension preoperatively should be screened for end-organ dysfunction by ECG, renal function parameters, and clinical evidence of HF. The current hypertension guidelines advocate confirmation of the diagnosis of hypertension using multiple measurements and ambulatory BP monitoring if necessary.[44]

It can be reasonable to defer nonurgent surgery in patients with poorly controlled Grade 3 hypertension (systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg), presence of previously-undiagnosed and untreated or a suspected case of secondary hypertension, considering the benefits of delaying surgery to optimize antihypertensive medications. Interestingly, in one study, immediate BP reduction with nifedipine in patients with uncontrolled hypertension was found to have similar complication rates but a shorter hospital stay compared to patients who deferred surgery.[45] However, there is no evidence of benefit from delaying surgery in patients with Grades 1 or 2 hypertension.[46] In such cases, antihypertensive medications should be continued during the perioperative period. The management of arterial hypertension should proceed according to existing guidelines.[44] It is recommended to keep perioperative BP at 70%–100% of baseline. Recommendations regarding the initiation and continuation of different antihypertensives are outlined in [Table 5].
Table 5: Recommendations on preoperative initiation and continuation of pharmacologic therapy for patients with hypertension and/or heart failure#

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Special preoperative cardiac considerations in patients with diabetes mellitus undergoing renal transplant surgery

For patients enlisted for renal transplantation surgery, a preoperative resting ECG must be done for those with a known history of CAD, peripheral vascular disease, or in the presence of cardiac symptoms. It is also reasonable for patients with DM without cardiac symptoms or a known history of CAD. ECG should be repeated every year after enlistment till the transplant procedure is over. Preoperative echocardiography for the assessment of left ventricular systolic and diastolic function is indicated at least once before surgery but periodically repeating echocardiography is not recommended.[47],[48]

All candidates with DM should also undergo noninvasive screening for CAD as per the Clinical Practice Guideline for Kidney Transplantation laid down by the Kidney Disease: Improving Global Outcomes (KDIGO).[47] The ACC and AHA recommend invasive or noninvasive imaging of the coronaries in asymptomatic patients only if three or more risk factors are present. Risk factors include age >65 years, DM, prior CAD, on dialysis for at least 1 year, left ventricular hypertrophy, smoking, hypertension, and dyslipidemia.[48] However, coronary revascularization before transplant in asymptomatic candidates with known CAD has not been found to reduce perioperative cardiac events. Those with advanced triple vessel CAD and those with EF ≤30% or severe valvular heart disease should be excluded from kidney transplantation unless their estimated survival is high as per national standards.[47] For patients undergoing coronary revascularization with stenting or bypass grafting, transplantation should be delayed for an appropriate amount of time as recommended by the patient's cardiologist and as outlined in section “coronary angiography and revascularization.” The cardioprotective drugs including antiplatelets, beta-blockers, and statins should all be continued while on the waiting list and perioperatively.

Special preoperative considerations in patients with diabetes mellitus undergoing bariatric surgery

Patients with obesity and DM awaiting bariatric surgery should be screened for obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS).[8],[49] OHS is defined as a combination of obesity (body mass index ≥30 kg/m2), daytime hypercapnia (arterial carbon dioxide tension ≥45 mmHg), and sleep-disordered breathing, after ruling out other disorders that may cause alveolar hypoventilation.[50] Numerous complications such as CAD, HF, stroke, and metabolic syndrome, are linked to obesity and OSA. OHS is linked to considerably higher morbidity, including angina pectoris, pulmonary hypertension (30%–88%), cor pulmonale, HF (including obesity-related cardiomyopathy), and increased perioperative mortality.[51] OHS should be screened preoperatively using screening questionnaires, serum bicarbonate levels, and peripheral oxygen saturations. Patients who are at high risk for OHS and having major surgery should be referred for further evaluation of pulmonary hypertension and sleep-disordered breathing. Appropriate preoperative initiation of positive airway pressure therapy and planning of perioperative techniques (anesthetic and surgical) should be done to optimize outcomes.[8]


  Conclusion Top


Patients with DM should be screened for cardiovascular risk before high-risk elective surgeries, irrespective of the presence of symptoms. Scoring systems should be used to decide the patient's preoperative risk. Preoperative evaluation should be based on the risk of the procedure and the patient's risk profile. Patients with nonischemic cardiac diseases such as HF, cardiac autonomic neuropathy, and hypertension require additional testing and optimization of their medications before surgery. Proper preoperative cardiac evaluation can grossly reduce perioperative mortality and adverse cardiovascular events.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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