Preoperative cardiovascular evaluation in patients with cancer

Cancer patients undergoing non-cardiac surgery represent a uniquely high-risk group for perioperative cardiovascular complications. These individuals frequently exhibit coronary artery disease, peripheral arterial disease, cardiomyopathy, valvular dysfunction, arrhythmias, pericardial disease, and heightened thrombotic or bleeding risk. Many surgeries in this population are time-sensitive rather than elective, limiting opportunities for optimization and requiring clinicians to balance competing risks. Current guidelines provide limited oncology-specific recommendations; however, several strategies can improve outcomes. These include incorporating cancer history into risk stratification, lowering thresholds for transthoracic echocardiography (TTE) and BNP screening in patients at risk for cancer therapy-related cardiac dysfunction (CTRCD), performing ECG in those at risk for QTc prolongation, and extending thromboprophylaxis for 4-5 weeks after major surgery. Multidisciplinary collaboration remains essential. Preoperative evaluation should integrate patient- and procedure-related risks, avoiding unnecessary testing in low-risk surgeries or patients with good functional capacity. Functional capacity assessment using METs or validated tools such as the Duke Activity Status Index (DASI), ECG, biomarkers, and surgical risk calculators (e.g., RCRI, ACS NSQIP) guide decision-making. Coronary revascularization should follow standard indications, such as significant left main or multivessel disease, rather than routine prophylactic intervention, as demonstrated by trials like CARP and reinforced by registry data in high-risk anatomy. Antithrombotic management, including continuation of aspirin, selective use of dual antiplatelet therapy, and bridging strategies with cangrelor or heparin in high-risk patients, further influences perioperative outcomes. By combining guideline-directed care with oncology-specific considerations, clinicians can optimize surgical safety and reduce cardiovascular complications.