High-Risk Cardiac Patient: Focus on Vascular Surgery

Abstract

Summary The ideal screening test for the detection of patients at increased risk for cardiac morbidity during vascular operations has not yet been developed. Nevertheless, a broad spectrum of preoperative tests are available and include resting, ambulatory, and exercise ECG monitoring, radionuclide angiography, dipyridamole thallium-201 myocardial imaging, and coronary angiography. Any of these tests may be indicated in the asymptomatic patient, depending on the analysis of individual cardiac-risk factors. At present, we perform resting ECG and dipyridamole thallium-201 imaging in most of our patients who undergo vascular operation. Coronary angiography is performed in selected patients in whom evidence of significant myocardial ischemia is found on these or other comparable tests. Preoperative pharmacologic therapy is directed toward the treatment of potential causes of myocardial ischemia, such as tachycardia and hypertension. In addition, pharmacologic interventions to reverse intraoperative and postoperative myocardial ischemia are equally important. In this regard, constant surveillance for myocardial ischemia in patients undergoing vascular operation is recommended because the presence of some CAD in these patients is the rule rather than the exception.