Cardiac risk stratification for high-risk vascular surgery.

Abstract

The best strategy for cardiac risk assessment before high-risk vascular surgery remains controversial. A cardiac risk stratification protocol was evaluated in patients undergoing high-risk vascular surgery. Our investigation paralleled the elaboration of the American College of Cardiology/ American Heart Association (ACC/AHA) Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery and is highly comparable to the proposed guidelines. A cardiac risk stratification protocol was evaluated prospectively in 203 patients scheduled for aortic surgery. Key points of the study were cardiac mortality/morbidity and cost-effectiveness. Patients were stratified into low (n = 101), intermediate (n = 79), and high (n = 23) cardiac risk after clinical predictors. After stratification, the degree of estimated functional capacity assessed by treadmill exercise and daily living activities and expressed by metabolic equivalents (METs) was critical for further cardiac evaluation. In intermediate-risk patients with an estimated functional capacity < 5 METs and in all high-risk patients, noninvasive cardiac testing and/or subsequent medical care were performed. Noninvasive testing was considered necessary in 41 patients, coronary angiography in 7, and myocardial revascularization in 1. Overall hospital mortality was 3.5%. Cardiac mortality and morbidity were 1% and 12.4%, respectively. Cardiac risk stratification for high-risk vascular surgery patients, according to a protocol similar to the ACC/AHA Guidelines for Cardiovascular Evaluation for Noncardiac Surgery, demonstrated excellent clinical outcome. This approach appears to be a safe and economical strategy for preoperative cardiac evaluation.