# Preoperative Stress Testing before Non-Cardiac Surgery

## TL;DR

This paper reviews the role of preoperative stress testing in predicting cardiovascular risk before non-cardiac surgery and highlights the need for further research.

## Contribution

The paper emphasizes the lack of consensus on stress testing methods and highlights the potential of diastolic stress tests for future research.

## Key findings

- There is no consensus on the best preoperative stress testing methods for predicting perioperative complications.
- The six-minute walk test is gaining importance in preoperative assessment and postoperative rehabilitation.
- Current evidence does not support a significant advantage of pharmacological stress over exercise stress imaging.

## Abstract

The current guidelines from various medical societies provide a good summary of
data regarding various preoperative exercise tests in patients prior to
non-cardiac surgical interventions. However, there is no consensus among experts
on the appropriateness of these methods for identifying risk groups for potential
perioperative complications. A large volume of published studies describes the
role of preoperative exercise stress testing impact in improving the prediction
of potential cardiovascular (CV) risk in patients after non-cardiac surgery.
Numerous stress tests are available in clinical practice, and the methods used
and the best choice depends on the purpose of the study and the availability of
equipment in the hospital. Traditionally, the value of exercise
electrocardiography (ECG), or ECG stress test, has been based on the belief that
it is beneficial for perioperative cardiac risk prediction. However, in the past
two decades, the key role of this method has lost its importance due to the
growing trend toward the use of imaging techniques. Moreover, in light of current
trends, the six-minute walk test (6MWT) is a helpful tool in preoperative assessment
and plays an important role in postoperative rehabilitation. Interestingly, the
recent finding showed how 6MWT affects the risk of postoperative complications.
Cardiopulmonary testing, as a dynamic clinical tool, determines the
cardiorespiratory status of a patient. Various clinical indications for
cardiopulmonary exercise testing include evaluation of therapy, stratification of
risk factors, diagnosis of disease, and control of physical activity. Stress
testing is one of the most practical ways of predicting perioperative risk and
managing patients. This test is based on ischemia provoked by pharmacological
agents or exercise. There is no established evidence of a significant advantage
of pharmacological stress over exercise stress imaging in subjects who are
capable enough to be physically active. All of these studies examined a stress
test for induced myocardial ischemia. Currently, there are no data on the use of
ischaemic stress tests, especially diastolic stress tests, in the assessment of
perioperative risk before non-cardiac surgical interventions. We consider it
promising and essential to continue research in this direction in patients with
coronary heart disease and other categories of cardiac patients, in particular,
comorbid and low-symptomatic individuals, before elective high-risk surgical
interventions.