From Clinic to Recovery · First Edition
Chapter 20 — Heart Disease, High Blood Pressure, and Surgery
Dr. Tamer Rushdy Elalfy · 13 min read
In this chapter
- 20.1 A stepwise cardiac assessment
- 20.2 Coronary stents and the timing of surgery
- 20.3 Heart medicines around surgery
- 20.4 Blood pressure on the day of surgery
- 20.5 Heart failure and valve disease
- 20.6 Pacemakers and defibrillators
- 20.7 Before and after the operation
- 20.8 Additional risks
- 20.9 Checklist
- 20.10 Warning signs
- References
Heart attacks, heart failure, and abnormal rhythms are leading causes of serious complications and death after non-cardiac surgery. Patients with known heart disease, coronary stents, pacemakers, or high blood pressure are often anxious about anesthesia, and families may fear that surgery will “strain the heart.” The surgeon’s task is to identify patients who need assessment before surgery, to avoid unnecessary tests that delay treatment, to manage heart medicines safely, and to explain the risks clearly. Coronary disease, diabetes, and smoking are common in the Gulf, often at a younger age, so these conversations are frequent.
Learning objectives After reading this chapter you should be able to:
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Table 20.1. Heart disease and surgery at a glance.
| At a glance | |
|---|---|
| Stepwise assessment | Urgency, active heart problems, combined risk, functional capacity, and whether tests would change the plan |
| After a coronary stent | Delay elective surgery at least 30 days after any stent; ideally 6 months after a drug-eluting stent, or 12 months after one placed for a heart attack |
| Heart medicines | Continue beta-blockers and statins; do not start a beta-blocker on the day of surgery; plan blood pressure medicines and blood thinners individually |
| Pacemakers and defibrillators | Bring the device card; check the device before and after surgery |
| The key counseling message | “We will check your heart carefully, keep the medicines that protect it, and watch you closely after the operation.” |
STEP 1 Assessing the heart and explaining the plan
20.1 A stepwise cardiac assessment
Current guidelines recommend a stepwise approach (Figure 20.1) [1, 2]. Emergency surgery proceeds without delay. Active heart problems, such as unstable chest pain, decompensated heart failure, serious arrhythmias, or severe valve disease, are treated first when time allows. For other patients, the risk of the operation is combined with patient factors, such as those in the Revised Cardiac Risk Index: high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and impaired kidney function [3]. Patients who can climb two flights of stairs without stopping usually need no further testing. Tests such as cardiac biomarkers, echocardiography, or stress testing are ordered only when the result would change management [1, 2].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 20.1. Five questions for cardiac assessment before non-cardiac surgery.
Script: explaining heart risk “Because you have [heart disease / a stent / high blood pressure], we look carefully at your heart before the operation. For most people with conditions like yours, the operation can go ahead safely.” “We will keep the tablets that protect your heart, and you will have heart monitoring during and after the operation. We may check a blood test that shows heart strain.” “Tell us at once if you have chest pain, breathlessness, or palpitations, before or after the operation.” |
20.2 Coronary stents and the timing of surgery
Surgery soon after coronary stenting carries a higher risk of stent thrombosis and heart attack, highest in the first weeks and months. The 2024 American guideline recommends delaying elective non-cardiac surgery for at least 14 days after balloon angioplasty and at least 30 days after any stent, ideally 6 months after a drug-eluting stent placed for stable disease, and 12 months after a stent placed for an acute coronary syndrome [1] (Table 20.2). Decisions about antiplatelet medicines must be made with the cardiologist (Chapter 22). Patients should never stop antiplatelet medicines on their own before surgery.
Table 20.2. Timing of elective surgery after coronary intervention, based on the 2024 ACC/AHA guideline.
| After | Usual minimum before elective surgery | Notes |
|---|---|---|
| Balloon angioplasty without a stent | At least 14 days | |
| Bare-metal stent | At least 30 days | |
| Drug-eluting stent for stable disease | Ideally 6 months; never within 30 days | Time-sensitive surgery may be considered earlier with the cardiologist |
| Stent for a heart attack or unstable angina | Ideally 12 months | Time-sensitive surgery is a joint decision |
20.3 Heart medicines around surgery
Beta-blockers that patients already take should be continued; starting a high-dose beta-blocker shortly before surgery increased stroke and death in a large trial and should be avoided [4]. Statins are continued. For angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, the 2024 ACC/AHA guideline rates omitting the dose 24 hours before surgery as reasonable to consider (may be beneficial) in selected patients with controlled blood pressure having higher-risk surgery, while continuing them is reasonable in patients with heart failure with reduced ejection fraction [1]; a 2024 trial found no difference in major complications between continuing and stopping these medicines 48 hours before major surgery, although continuing them was associated with more low blood pressure during anesthesia [5]. This is not a flat rule either way: follow the hospital protocol, and consider the patient’s heart failure status. Table 20.3 summarizes the usual approach.
Table 20.3. Usual approach to heart medicines before surgery. Always follow the hospital protocol.
| Medicine | Usual approach before surgery | Notes |
|---|---|---|
| Beta-blockers | Continue, including on the morning of surgery | Do not start on the day of surgery [4] |
| Statins | Continue | |
| ACE inhibitors and angiotensin receptor blockers | May be omitted 24 hours before higher-risk surgery in selected patients with controlled blood pressure, according to protocol; continue in heart failure with reduced ejection fraction | Not a flat rule either way; watch for low blood pressure [1, 5] |
| Diuretics | Often omitted on the morning of surgery | Restart when drinking normally |
| Nitrates and calcium channel blockers | Continue | |
| Antiplatelets and anticoagulants | Individual plan with the cardiologist | See Chapter 22 |
| SGLT2 inhibitors (for heart failure) | Stop before surgery | See Chapter 18 |
20.4 Blood pressure on the day of surgery
Many patients arrive anxious with a raised blood pressure. Mild to moderate hypertension is not a reason to postpone surgery; very high readings, around 180/110 mmHg or above, or high blood pressure with symptoms or organ damage, need assessment before elective surgery [2]. Patients should take their usual blood pressure medicines as instructed, and newly found hypertension should be referred for long-term treatment.
20.5 Heart failure and valve disease
Patients with heart failure should be at their best fluid balance before elective surgery, and those with symptoms that have recently worsened need review first. A new murmur, unexplained breathlessness, or fainting suggests possible valve disease, particularly aortic stenosis, and should be assessed with echocardiography before major elective surgery [2].
20.6 Pacemakers and defibrillators
Patients should bring their device card. The device should have been checked within the recommended interval before surgery. Electrical diathermy can interfere with these devices; defibrillator shock therapies are usually suspended during surgery with external defibrillation pads in place, and pacemakers may be reprogrammed for patients who depend on them. The device is checked again after surgery when it has been reprogrammed or exposed to interference [6].
STEP 2 Preparation and recovery
20.7 Before and after the operation
- Bring all heart medicines, the device card, and any recent heart test results.
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Morning of surgery. Take the medicines on the written plan, with a sip of water.
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After surgery. Heart monitoring and, in high-risk patients, blood tests for heart strain (troponin) may be used according to protocol, because heart injury after surgery is often silent [2].
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Pain and anxiety. Good pain relief reduces strain on the heart.
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Mobilize early, and restart usual heart medicines as soon as possible.
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Atrial fibrillation can begin after surgery; report palpitations.
Caution: silent heart injury after surgery Heart attacks after surgery often cause no chest pain, because of pain medicines and the stress of surgery. Unexplained low blood pressure, breathlessness, fast heart rate, confusion, or new arrhythmia should prompt an ECG and troponin test. |
STEP 3 Questions patients ask
“Do I need heart tests before my operation?”
Only if they would change what we do. If you can climb two flights of stairs without stopping, you often need no extra tests [1].
“I had a stent recently. Can I have my operation?”
For a planned operation, it is usually safer to wait, ideally 6 months after a stent for stable disease or 12 months after a heart attack. We will decide with your cardiologist [1].
“Should I stop my aspirin or other blood thinner?”
Never stop them yourself. We will make a plan with your cardiologist (Chapter 22).
“Should I take my heart tablets on the morning of surgery?”
Most, yes, especially beta-blockers. Some blood pressure tablets and water tablets may be stopped that morning. Follow your written plan.
“My blood pressure is high today. Will you cancel?”
Usually not. Many people are nervous on the day. Only very high readings need us to pause and check [2].
“I have a pacemaker. Is the operation safe?”
Yes. Bring your device card. We will check it and adjust it if needed during the operation [6].
“Can I fast in Ramadan with my heart medicines?”
Many people can, with the doses re-timed. Discuss it with your cardiologist, and do not fast until you have recovered from surgery.
“Does shisha affect my heart?”
Yes. Shisha and cigarettes both strain the heart and blood vessels. Stopping helps your heart and your recovery.
STEP 4 Risks, warning signs, and consent
20.8 Additional risks
Table 20.4. Additional risks for patients with heart disease. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Less common | Heart strain or heart attack after surgery, often silent | Depends on patient and operation risk [unit data] | “Your heart risk is [X] in 100. We will monitor you.” |
| Less common | Irregular heartbeat (atrial fibrillation) | [unit data] | “An irregular heartbeat can start after surgery and is treatable.” |
| Less common | Worsening heart failure | [unit data] | “Fluid can build up; we watch your weight and breathing.” |
| Rare but serious | Stent thrombosis, stroke, or cardiac death | [unit data] | “Rarely, serious heart or brain problems occur.” |
20.9 Checklist
Before surgery ☐ Stepwise cardiac assessment done; tests ordered only if they change the plan. ☐ Stent type and date recorded; timing and antiplatelet plan agreed with the cardiologist. ☐ Written plan for each heart medicine; beta-blockers and statins continued. ☐ Blood pressure reviewed; very high readings assessed. ☐ Pacemaker or defibrillator check arranged; device card seen. ☐ Heart risk explained in natural frequencies; warning signs taught. |
20.10 Warning signs
Table 20.5. Green, amber, and red warning signs for heart problems after surgery.
| Level | Signs | What to do |
|---|---|---|
| Green | Mild tiredness in the first weeks Ankles slightly swollen after surgery, improving | Expected. Keep taking your heart medicines. |
| Amber | Palpitations or a fast, irregular pulse Ankle swelling or weight gain of 2 kg in 2 days Breathless with less activity than usual | Call your doctor or the clinic the same day. |
| Red | Chest pain or pressure lasting more than a few minutes Breathless at rest or when lying flat Fainting Sudden weakness, numbness, or speech problems | Call an ambulance now. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Complete the medicine plan with the patient, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Your Heart and Your Operation For people with heart disease, stents, pacemakers, or high blood pressure. |
My heart details
Stent: date ________ type ________ Pacemaker or defibrillator: ☐ yes ☐ no Cardiologist: ______________
My medicine plan
| Medicine | Before surgery | Morning of surgery | Restart |
|---|---|---|---|
Before your operation
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Never stop aspirin or other blood thinners on your own. Follow the plan agreed with your cardiologist.
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Take your heart tablets as written above, with a sip of water.
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Bring all your medicines, your device card, and recent heart test results.
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Stop smoking and shisha.
After your operation
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You may have heart monitoring and blood tests.
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Tell the nurse at once about chest pain, breathlessness, or palpitations.
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Walk as soon as you can.
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Restart your heart medicines as planned.
Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Mild tiredness; slightly swollen ankles that are improving | This is normal. Keep taking your medicines. |
| AMBER | Palpitations; ankle swelling or weight gain of 2 kg in 2 days; breathless with less activity | Call your doctor or us today. |
| RED | Chest pain or pressure lasting more than a few minutes; breathless at rest or lying flat; fainting; sudden weakness or speech problems | Call an ambulance now. |
My contacts Surgical team: ______________________ Cardiologist: ______________________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. Thompson A, Fleischmann KE, Smilowitz NS, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery. Circulation. 2024;150(19):e351-e442.
2. Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826-3924.
3. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.
4. POISE Study Group; Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847.
5. Legrand M, Futier E, Leone M, et al. Effect of renin-angiotensin system inhibitor continuation vs discontinuation on outcome after major surgery: the STOP-or-NOT randomized clinical trial. JAMA. 2024;332(12):970-978.
6. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) expert consensus statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011;8(7):1114-1154.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.